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Saatja: "ABDUSALYAMOVA, Malika" <[email protected]> Saaja: "Helen Sõber" Teema: Let to MOH EST on MR ASU Kuupäev: 2024-04-04 09:59 Please see the attached correspondence sent from the World Health Organization, Regional Office for Europe. One or more attachments may be included. Veuillez vous référer à la correspondance ci-jointe du Bureau régional de l'Europe de l'Organisation mondiale de la santé. Une ou plusieurs annexes peuvent être jointes. Mit der Bitte um Kenntnisnahme der beiliegenden Korrespondenz (eine oder mehrere Anlagen), Weltgesundheitsorganisation, Regionalbüro für Europa. См. прикрепленные письма от Европейского регионального бюро Всемирной организации здравоохранения (один или несколько прикрепленных файлов) WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTÉ WELTGESUNDHEITSORGANISATION ВСЕМИРНАЯ ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ Date: 3 April 2024 REGIONAL OFFICE FOR EUROPE BUREAU RÉGIONAL DE L’EUROPE REGIONALBÜRO FÜR EUROPA Ms Helen Sõber ЕВРОПЕЙСКОЕ РЕГИОНАЛЬНОЕ БЮРО Adviser European Union Affairs and International Co-operation Head office: Department UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Ministry of Social Affairs Tel.: +45 45 33 70 00; Fax: +45 45 33 70 01 Suur-Ameerika 1 Tallinn 10122 Email: [email protected] Website: https://www.who.int/europe Estonia Dear Ms Sõber, Annual status update (ASU) on measles and rubella elimination for 2023 The Vaccine-preventable Diseases and Immunization programme of the WHO Regional Office for Europe is pleased to inform you that the 13th meeting of the European Regional Verification Commission for Measles and Rubella Elimination (RVC) is planned to take place in September of 2024. The aim of the meeting is to review the status and achievements towards measles and rubella elimination in Member States and in the Region as a whole. All Member States are requested to submit their completed annual status update on measles and rubella elimination (ASU) for the year 2023 by no later than 30 June 2024. An ASU form for 2023 and relevant documents should be submitted to the WHO Regional Office for Europe (RVC Secretariat) by e-mail ([email protected]). Attached with this e-mail is a template for the 2023 ASU and an Excel file with pre-prepared tables and formulas to help in calculating data. It is important to ensure that ASUs are prepared with national technical experts and approved by the respective national verification committee (NVC), as their independent review is critical for the verification process. NVC’s review should be based on accurate data, consistent with other national data routinely submitted to the Regional Office, and other information that is not routinely provided in monthly and annual reporting to WHO. Please contact the RVC Secretariat for any issue you may have related to the deadline or for any other queries ([email protected]). The RVC and its Secretariat are committed to provide you with any support that you may require. We would like to stress that your efforts in documenting the absence of endemic transmission in your country are highly appreciated and critical to achieving measles and rubella elimination in the Region. Sincerely yours, Mr Robb Butler Director Division of Communicable Diseases, Environment and Health UN City, Marmorvej 51 Tel.: +45 45 33 70 00 Email: [email protected] DK-2100 Copenhagen Ø Fax: +45 45 33 70 01 Website: https://www.who.int/europe Denmark Copy for information to: Ms Triin Uusberg, Head, European Union Affairs and International Co-operation Department, Ministry of Social Affairs, Suur-Ameerika 1, 10129 Tallinn, Estonia H.E. Ms Riia Salsa-Audiffren, Ambassador Representative of the Republic of Estonia, Permanent Mission of the Republic of Estonia to the United Nations Office and other international organizations in Geneva, Chemin du Petit-Saconnex 28A, CH-1209 Genève, Switzerland H.E. Mr William Mart Laanemäe, Ambassador Extraordinary and Plenipotentiary, Embassy of the Republic of Estonia, Frederiksgade 19, 4th floor, 1265 Copenhagen K, Denmark Ms Kristina Köhler, Liaison Officer, WHO Country Office, Estonia, Paldiski Road 81, 10617 Tallinn, Estonia –2– 20 2 3 Annual Status Update on Measles and Rubella Elimination (write name of country) Dear National Verification Committee - NVC and national technical counterparts, dear colleagues, We kindly ask you to follow the definitions (please see Annex 1.1) and instructions provided in this form, and to enter numbers or text as required in each segment (table, text box, other). If you are using your own definitions and indicators, please provide an explanation and clarification why and how these could be considered equivalent to or as an adequate replacement for the WHO definitions and indicators. If the NVC would like to provide additional data and information to the RVC, please submit them as separate document(s). We would still kindly request from you to submit your ASU and all relevant additional documents as attachments to an e-mail to RVC Secretariat, using address [email protected] . You may also copy any of Vaccine-preventable Diseases and Immunization technical officers cooperating with you in preparation of the ASU and verification process. Please follow up with us to confirm that we received your ASU, and on any other issue that may need our support or attention. We are planning to re-establish online submission or create online data entry platform i n near future. This update for 202 3 is to be submitted to the WHO Regional Office for Europe by 30 June 202 4 . The National Verification Committee (NVC) conclusion on measles and rubella elimination status in 2023 Please provide NVC statement on the status of measles and rubella viruses’ circulation in your country, based on the information collected and provided by the national surveillance and immunization systems. Tick one of the boxes below as deemed appropriate and provide rationale (main facts that led to the NVC’s conclusion) in the text box below. If you have difficulties in deciding which one of the three status definitions for measles and rubella elimination applies , please leave the boxes unchecked and explain in the text box. Measles FORMCHECKBOX Endemic FORMCHECKBOX Elimination/Interrupted endemic transmission FORMCHECKBOX Re-established endemic transmission The NVC conclusion is based on the following: (please see the guiding text below, then delete and replace it with your text addressing the mentioned areas) Epidemiology of measles in 2023 – number and description of cases and outbreaks (person-time-place, seasonality, immunization status, known origin, rate of confirmation and discarding of cases). Even it is not directly related to verification, you may include information about measles mortality and cases of subacute sclerosing panencephalitis (SSPE). Measles surveillance quality in 2023 – systems quality and capacity to detect, report, investigate and confirm/discard suspected cases all over the country for the entire year, performance against surveillance indicators, other reliable indicators used in country to confirm adequate surveillance quality and performance, additional activities (active case finding, retrospective case/data analysis, addressing “silent” territories and populations), integration with laboratory segment of surveillance for confirming cases and genotypes/lineages (sporadic cases and outbreaks). Molecular epidemiology of measles in 2023 – comprehensive analysis of epidemiological and laboratory data on detected genotypes/lineages of measles viruses and extended to analysis of available data from the previous and following year looking for/to exclude continuous circulation of &gt;12 months. Activities to increase population immunity in 2023 – routine immunization programme coverage at national and subnational level, and especially where suboptimal programme performance exists (e.g. age cohorts, territories and/or specific population with known low coverage), supplemental immunization activities and coverage, additional studies and surveys about immunity to measles and rubella (MR). Sustainability of and commitment to activities on MR elimination in 2023 – political commitment of decision-making structures and main players, involvement of partners, promotion of and advocacy for elimination, sustainability of immunization programme, political and technical regulations and guidelines developed or renewed, security of funds and vaccine supply, organized activities aimed at particular groups (e.g. health care workers to increase knowledge or general population to increase demand). Characteristics and quality of data for 2023 – Are the data complete, available, valid, representative, consistent? Are any additional data from other sources used to validate existing data and ensure adequate understanding of measles epidemiology and assessment of elimination status? Rubella FORMCHECKBOX Endemic FORMCHECKBOX Elimination/Interrupted endemic transmission FORMCHECKBOX Re-established endemic transmission The NVC conclusion is based on the following: (please see the guiding text below, then delete and replace it with your text addressing the mentioned areas) Epidemiology of rubella and CRS in 2023 – number and description of cases and outbreaks (person-time-place, seasonality, immunization status, known origin, rate of confirmation and discarding of cases). Rubella and CRS surveillance quality in 2023 – systems quality and capacity to detect, report, investigate and confirm/discard suspected cases all over the country for the entire year, performance against surveillance indicators, other reliable indicators used in country to confirm adequate surveillance quality and performance, additional activities (active case finding, retrospective case/data analysis, addressing “silent” territories and populations), integration with laboratory segment of surveillance for confirming cases and genotypes/lineages (sporadic cases and outbreaks). Molecular epidemiology of rubella in 2023 – comprehensive analysis of epidemiological and laboratory data on detected genotypes/lineages of measles viruses and extended to analysis of available data from previous and following years looking for/to exclude continuous circulation of &gt;12 months. Activities to increase population immunity in 2023 – routine immunization programme coverage at national and subnational level, and especially where suboptimal programme performance exists (e.g. age cohorts, territories and/or specific population with known low coverage), supplemental immunization activities and coverage, additional studies and surveys about immunity to MR. Sustainability of and commitment to activities on MR elimination in 2023 – political commitment of decision-making structures and main players, involvement of partners, promotion of and advocacy for elimination, sustainability of immunization programme, political and technical regulations and guidelines developed or renewed, security of funds and vaccine supply, organized activities aimed at particular groups (e.g. health care workers to increase knowledge or general population to increase demand). Characteristics and quality of data for 2023 – Are data complete, available, valid, representative, consistent? Are any additional data from other sources used to validate existing data and ensure adequate understanding of rubella (with CRS) epidemiology and assessment of elimination status? These conclusions are approved by the National Verification Committee (NVC) Name NVC status Professional p osition Organization Contact details (email, tel.) Signature 1 Chairperson 2 Secretariat person* 3 Member 4 Member 5 Member 6 Member *Person with administrative duties, who may also be responsible for documenting, maintaining records and overseeing logistics. This person may be from the national immunization or surveillance programme. Add rows if needed In the text box below please provide the NVC and national technical counterparts’ response to any RVC request for additional information or clarification from previous years. Text box Sections of the ASU form Please complete sections 1-3, and us/add forms from Section 4 as needed, to report outbreaks and supplemental immunization activities (SIA). Please use provided Excel file to help you analyse the data and complete the ASU, and then send the Excel file to the RVC/Secretariat along with the ASU form. Additional information to help you analyse the data and complete the forms is provided in Annex 1. In your e-mail m e ssage with ASU and Excel tool for 2023 please include the latest versions of national plan/document on measles and rubella elimination and the latest document (regulation/plan/guidelines) on response to measles and rubella outbreaks. We would appreciate any format of information - document in Word or PDF, web address link to online version, or any other, and information in any language (English is preferable but we are grateful for documents in official national languages as well). Section 1: Country measles and rubella profile for 2023 1.1 Epidemiologic analysis of measles, rubella and CRS 1.2 Laboratory performance - national framework for MR laboratory testing 1.3 Performance of measles and rubella surveillance against indicators 1.4 Population immunity to measles and rubella Section 2: Update of general programme activities by components Section 3: Activities of the National Verification Committee (NVC) and its Secretariat 3.1 Activities of the NVC in the year under review 3.2 The NVC Secretariat (list of national staff involved in preparation of ASU) – UPDATE CONTACT DATA Section 4: Additional data on measles, rubella and CRS in 2023 4.1 Maps and epi curves with distribution of suspected and confirmed measles and rubella cases and measles and rubella outbreaks in 2023 4. 2 Technical report on SIA or ORI, if any conducted Annex 1: WHO guiding documents and examples 1.1 Definitions 1.2 Description of “Indicators and targets” for measuring performance of measles and rubella surveillance 1.3 Sustain measles and rubella elimination after verification - Discussion points for NVC and its Secretariat on risk for re-establishing endemic transmission of diseases Abbreviations ASU Annual Status Update (form) CRS congenital rubella syndrome EQA external quality assurance MCV measles-containing vaccine MeaNS WHO Measles Nucleotide Surveillance online database (www.who-measles.org) NVC National Verification Committee ORI Outbreak response immunization RCV rubella-containing vaccine RubeNS WHO Rubella Nucleotide Surveillance online database (www.who-rubella.org) RVC Regional Verification Commission SIA Supplemental immunization activities Section 1: Country measles and rubella profile for 2023 Epidemiologic analysis of measles, rubella and CRS Progress towards measles and rubella elimination , 20 2 1 - 2023 - Incidence of measles and rubella and total number of CRS cases in last three years 575945 8387715 0 0 Incidence or number of cases 202 1 202 2 2023 Remarks Measles incidence per 1 million population FORMTEXT FORMTEXT Numerator: FORMTEXT FORMTEXT FORMTEXT FORMTEXT Numerator: FORMTEXT FORMTEXT FORMTEXT FORMTEXT Numerato r : FORMTEXT FORMTEXT Text Rubella incidence per 1 million population FORMTEXT FORMTEXT Numerator: FORMTEXT FORMTEXT FORMTEXT FORMTEXT Numerator: FORMTEXT FORMTEXT FORMTEXT FORMTEXT Numerator: FORMTEXT FORMTEXT Text Number of CRS cases FORMTEXT FORMTEXT FORMTEXT Text Country population : number used as denominator to calculate incidence for 2023 in table above : ( please enter number ) The numerator is the total number of measles/rubella cases including laboratory-confirmed, epidemiologically linked and clinically compatible cases but excluding imported cases . For CRS cases please provide total number of cases classified as CRS , excluding imported cases . Epidemiology of measles, rubella and CRS in 2023 Measles and rubella surveillance is organized as: FORMCHECKBOX Disease-specific surveillance (measles surveillance, rubella surveillance) FORMCHECKBOX Rash and fever surveillance (syndrome-based) FORMCHECKBOX Both types of the above surveillance systems are in place FORMCHECKBOX Other (please describe in text box below) Text box Are specimens from ALL suspected cases routinely tested for both diseases by a laboratory ? FORMCHECKBOX No FORMCHECKBOX Yes, for both diseases, in parallel or in sequence (if testing for one disease is negative) FORMCHECKBOX Yes, but partially/for some of cases (if there are national guidelines or proposed testing algorithm – please explain): Text box Number of measles and rubella cases in 2023 Total number of suspected cases (from diseases-specific and syndrome-based surveillance) Total number of cases classified as measles or rubella (laboratory-confirmed, epidemiologically linked and clinically compatible cases) Number of d iscarded cases (please indicate if these are discarded for both diseases) Measles Rubella Value in cell “Total number of suspected cases” should be equal to the sum of values presented in “ Total number of cases c lassified as measles or rubella ” and “ Total number of d iscarded cases ” . I nclude laboratory-confirmed, epidemiologically linked and clinically compatible cases , regardless of origin (include imported) . If suspected cases are systematically investigated/tested for both diseases in your surveillance system (syndromic-based surveillance ; simultaneous or sequential testing in laboratories), cases suspected for measles may be included in the total number of cases suspected for rubella, and conversely , cases suspected for rubella may be included as cases suspected for measles. Number of measles cases, by case classification and origin of infection Measles Laboratory-confirmed (A) Epidemiologically linked (B) Clinically compatible (C) Total (A+B+C) Imported Import-related (I) Endemic (II) Unknown origin (I II ) Total (excluding imported cases) (I + II + III) Note: Please use the E xcel spreadsheet provided with this ASU, as it can help you in completing this table . Number of rubella cases, by case classification and origin of infection Rubella Laboratory-confirmed (A) Epidemiologically linked (B) Clinically compatible (C) Total (A+B+C) Imported Imported-related (I) Endemic (II) Unknown origin (I II ) Total (excluding imported cases) (I + II + III) Note: Please use the Excel spreadsheet provided with this ASU, as it can help you in completing this table . N umber of CRS cases, by case classification and origin of infection CRS Laboratory-confirmed (A) Epidemiologically linked (B) Clinically compatible (C) Total (A+B+C) Imported Imported-related (I) Endemic (II) Unknown origin (I II ) Total (excluding imported cases) (I + II + III) Note: Please use the Excel spreadsheet provided with this ASU, as it can help you in completing this table . Age and vaccination status of laboratory-confirmed, epidemiologically linked or clinically compatible cases of measles and rubella Age and vaccination status of measles cases Measles &lt; 1 year 1-4 years 5-9 years 10-14 years 15-19 years 20-29 years 30 years Unknown age Total 0 doses 1 dose 2 or more doses Unknown status Total Age and vaccination status of rubella cases Rubella &lt; 1 year 1-4 years 5-9 years 10-14 years 15-19 years 20-29 years 30 years Unknown age Total 0 doses 1 dose 2 or more doses Unknown status Total List of administrative territories with measles and rubella cases Total number of confirmed measles cases by month (classified as laboratory-confirmed, epidemiologically linked or clinically compatible), regardless of origin (including imported cases ) Administrative territory and its population size Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Total Add as many rows as you may need for territories – one and the same type/level of administrative organization (district, region, municipality) that provides routine diseases surveillance data in your system. Total number of confirmed rubella cases (classified as laboratory-confirmed, epidemiologically linked or clinically compatible), regardless of origin (including imported cases) Administrative territory and its population size Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Total Add as many rows as you may need for territories– one and the same type/level of administrative organization (district, region, municipality) that provides routine diseases surveillance data in your system. Outbreaks in 2023 and molecular epidemiology NOTE : If genotyping data are available, please note that each outbreak or chain of transmission should have only one genotype-variant . If more than one genotype-variant is reported for an outbreak, this refers to more than one outbreak/chain of transmission and should be described as two separate outbreaks/chains of transmission in the table. Countries with comprehensive data are encouraged to use the additional Excel sheets provided as tool for better visualization. Please provide definition for an outbreak of measles and rubella used in your country in the text box below: Text box Measles Measles outbreaks and sporadic cases in 2023 by availability of the genotype information MEASLES Genotyped Not genotyped Total Number of outbreaks/chains of transmission Number of cases that are part of outbreaks/chains of transmission (I) Number of sporadic cases that are not part of outbreaks/ chains of transmission (II) Total number of cases (I +II) The v alue in the cell highlighted in orange should be the total number of cases classified as measles and the same as the value for the Total number of cases classified as measles in table 1.1.1.c Measles outbreaks in 2023 (list ALL outbreaks ; i f your country only reported sporadic measles cases and NO outbreaks, please go directly to table d ) Outbreak ID Name of the affected territory (national, or list of affected sub-national territories ) Duration (Date of onset of the first case , date of onset of the last case; or “ongoing” ) (dd/mm/yyyy) Total num ber of cases in outbreak in 2023 First case by origin (Imported or not-imported) Outbreak genotyped ( Y es/ N o) Outbreak report form attached to the ASU (Yes/No) Add as many rows a s you need Genotyped measles outbreaks/chain s of transmission Genotype-variant (MeaNS distinct sequence ID) as defined in Annex 1. Outbreaks (list all IDs) Name of the affected territory (national, or list of affected subnational territories) Total number of cases in 2023 Duration Documented importation for first case (yes/no) Are there sporadic cases with the same variant that are not part of the identified outbreak/chain of transmission? FORMCHECKBOX Yes FORMCHECKBOX No Date of onset of the first case Date of onset of the last case or ‘ongoing’ If yes, how many cases? (enter data at the bottom of the table) Date of first sporadic case Date of last sporadic case SUM - Total number of genotyped outbreaks/ chains of transmission SUM - Total number of cases in outbreaks/ chains of transmission SUM - Total number of sporadic cases with genotype Add as many rows as you need, or remove not used rows (e.g. only one genotype-variant detected) Measles sporadic cases with different genotype-variant(s) than those reported in table c) Please fill in this table ONLY IF 1) there were NO genotyped outbreaks at all reported in 2023 or 2) if NO outbreaks had the same genotype-variant(s). Otherwise, please include the sporadic cases above in the last column of table c). Genotype-variant (MeaNS distinct sequence ID) as defined in Annex 1 Case ID /Epid . No . Name of subnational territory from where case was reported Date of onset Documented importation (yes/no) SUM - Total number of cases Add as many rows as you need, or remove not used rows (e.g. only one genotype-variant detected 1.1.4.2 Rubella Rubella outbreaks and sporadic cases in 2023 by availability of the genotype information RUBELLA Genotyped Not genotyped Total Number of outbreaks/chains of transmission Number of cases that are part of outbreaks/chains of transmission (I) Number of sporadic cases that are not part of outbreaks/chains of transmission (II) Total number of cases (I + II) The v alue of the cell highlighted in orange should be the total number of cases classified as rubella and the same as the value for the Total number of cases classified as rubella in table 1.1.1.c Rubella outbreaks in 2023 (list ALL outbreaks; i f your country only reported sporadic rubella cases and NO outbreaks, please go directly to table d) Outbreak ID Name of the affected territory (national, or list of affected sub-national territories) Duration (Date of onset of the first case, date of onset of the last case; or “ongoing”) (dd/mm/yyyy) Total number of cases in outbreak in 2023 First case by origin (Imported or not-imported) Outbreak genotyped (Yes/No) Outbreak report form attached to the ASU (Yes/No) Add as many rows as you need Genotyped rubella outbreaks Genotype-variant (RubeNS sequence ID) Outbreaks (list all IDs) Name of the affected territory (national, or list of affected subnational territories) Total number of cases in 2023 Duration Documented importation for first case (yes/no) Are there sporadic cases with the same variant that are not part of the identified outbreak/chain of transmission? FORMCHECKBOX Yes FORMCHECKBOX No Date of onset of the first case Date of onset of the last case or ‘ ongoing ’ If yes, how many cases? (enter data at the bottom of the table) Date of first sporadic case Date of last sporadic case SUM - Total number of genotyped outbreaks/ chains of transmission SUM - Total number of cases in outbreaks/ chains of transmission SUM - Total number of sporadic cases with genotype Add as many rows as you need, or remove not used rows (e.g. only one genotype-variant detected) Rubella sporadic cases with different genotype-RubeNS sample ID than those reported in table c). Please fill in this table ONLY IF 1) there were NO genotyped outbreaks at all reported in 2023 or 2) if NO outbreaks had the same genotype-variant(s). Otherwise, please include the sporadic cases above in the last column of table c). Genotype-variant (RubeNS sequence ID) Case ID /Epid . No . Name of subnational territory from where case was reported Date of onset (dd/mm/yyyy) Documented importation (yes/no) SUM - Total number of cases Add as many rows as you need, or remove not used rows (e.g. only one genotype-variant detected) Non- genotyped rubella sporadi c cases Case ID /Epid. No. Name of subnational territory from where case was reported Date of onset (dd/mm/yyyy) Documented importation (yes/no) SUM - Total number of cases Laboratory performance - national framework for measles and rubella laboratory testing in 2023 Standard laboratory procedures for testing and case confirmation Please select ONE of the following: FORMCHECKBOX IgM serology is the first line of laboratory investigation; case confirmation may rely on additional tests if needed. FORMCHECKBOX Molecular detection is the first line of laboratory investigation; serology may be additionally performed or not. FORMCHECKBOX Other case confirmation procedure, please specify: FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT Testing and confirmation of cases by laboratory proficiency Select all that apply regarding testing of measles, ru bella and CRS suspected cases (more than one may apply) FORMCHECKBOX Testing conducted by WHO-accredited measles–rubella reference laboratory/ laboratories . FORMCHECKBOX Testing conducted by l aboratories having an established quality assurance programme with oversight by a WHO-accredited laboratory. FORMCHECKBOX Testing conducted by l aboratories having an established quality assurance programme and accredited by a national body/institution. Please specify EQA programme FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT Name of national accrediting body FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT Accreditation standard(s) FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMCHECKBOX Other (please comment/describe) Number o f suspected cases tested in 2023 by type of the laboratory Systematic screening studies as well as any other results of general screenings of population should not be reported in this form ( e.g. survey for rubella in pregnancy) . Laboratory performing the test Number of suspected cases tested for measles Number of suspected cases tested for rubella Number of suspected cases tested for CRS WHO-accredited lab(s) Proficient labs overseen by WHO - accredited lab Nationally accredited labs Other labs Total Performance of measles and rubella surveillance against indicators Please u se th e Excel spreadsheet provided with this ASU 2023 to calculate rates or percentage s required as surveillance indicators and insert the calculated values in the tables of this section . Please add any comment s or clarification s in the “Remarks” column. Measles surveillance performance indicators Standard indicators Indicator Value for indicator Numerator Denominator Remarks Timeliness of reporting (to national level in %) (T) Target: ≥80% T = (A*100)/B FORMTEXT % FORMTEXT (A) = number of reports submitted by deadline FORMTEXT FORMTEXT (B) = number of expected reports submitted Completeness of reporting (to national level in %) (C) Target: ≥80% C = (E*100)/B FORMTEXT % FORMTEXT FORMTEXT ( E ) = number of submitted reports FORMTEXT (B) = number of expected reports Rate of laboratory investigations in % (L ) Target: ≥80% L = (F*100)/G FORMTEXT % FORMTEXT (F) = number of suspected measles cases with adequate specimens collected and tested in a proficient laboratory FORMTEXT (G) = number of suspected measles cases Rate of discarded cases (D) Target: ≥2/100,000 D = (H*100,000)/J FORMTEXT /100,000 FORMTEXT (H) = number of suspected measles cases investigated and discarded as non- measles FORMTEXT FORMTEXT (J) = population Representativeness of reporting discarded cases in % (R) Target: ≥80% R = (K*100)/M FORMTEXT % FORMTEXT (K) = number of subnational administrative territories reporting the rate at least 2 per 100,000 FORMTEXT (M) = number of subnational administrative territories Viral detection in % (V) Target: ≥80% V = (P*100)/Q FORMTEXT % FORMTEXT (P) = number of chains of transmission of measles for which adequate samples have been submitted for viral detection/genotyping FORMTEXT (Q) = number of chains of transmission identified Viral detection for sporadic cases in % (V1) Target: ≥80% V 1 =( p *100)/ q FORMTEXT % FORMTEXT ( p ) = number of sporadic cases from which samples were obtained and sequenced in an accredited laboratory FORMTEXT FORMTEXT ( q ) = number of sporadic cases * if possible, sporadic cases should be genotyped in countries that are approaching elimination or have already achieved elimination . Origin of infection identified in % (O) Target: ≥80% O = (W*100)/X FORMTEXT % FORMTEXT ( W ) = number of measles cases for which the origin of infection (imported, import-related, endemic) has been identified FORMTEXT (X) = total number of measles cases Timeliness of investigation in % (I) Target: ≥80% I = (Y*100)/Z FORMTEXT % FORMTEXT (Y) = number of measles cases with an adequate investigation FORMTEXT (Z) = number of suspected measles cases Alternative indicators – If the above standard indicators could be calculated using the available data, there is no need to provide alternative indicators. If data is not available to calculate the standard indicators, NVC should use these alternative indicators to assess the performance of measles surveillance. Indicator Value for indicator Numerator Denominator Remarks Timeliness of notification (in %; alternative to Timeliness and Completeness indicator) (Tn) Target: ≥80% Tn = ( CC *100)/ G FORMTEXT % FORMTEXT FORMTEXT (CC) = number of reports submitted within 48 hours FORMTEXT FORMTEXT ( G ) = number of suspected measles cases Rate of cases tested negative for measles IgM (alternative to Rate of Discarded Cases indicator) (N) Target: ≥2/100,000 N = ( DD *100,000)/J FORMTEXT /100,000 FORMTEXT FORMTEXT (DD) = number of negative IgM test results FORMTEXT FORMTEXT (J) = population Rubella surveillance performance indicators Standard indicators Indicator Value for indicator Numerator Denominator Remarks Timeliness of reporting (to national level in %) (T) Target: ≥80% T = (A*100)/B FORMTEXT % FORMTEXT (A) = number of reports submitted by deadline FORMTEXT FORMTEXT (B) = number of expected reports submitted Completeness of reporting (to national level in %) (C) Target: ≥80% C = ( E *100)/B FORMTEXT % FORMTEXT ( E ) = number of submitted reports FORMTEXT FORMTEXT (B) = number of expected reports Rate of laboratory investigations in % (L ) Target: ≥80% L = (F*100)/G FORMTEXT % FORMTEXT (F) = number of suspected rubella cases with adequate specimens collected and tested in a proficient laboratory FORMTEXT FORMTEXT (G) = number of suspected rubella cases Rate of discarded cases (D) Target: ≥2/100,000 D = (H*100,000)/J FORMTEXT /100,000 FORMTEXT (H) = number of suspected rubella cases investigated and discarded as non- rubella FORMTEXT FORMTEXT (J) = population Representativeness of reporting discarded cases in % (R) Target: ≥80% R = (K*100)/M FORMTEXT % FORMTEXT (K) = number of subnational administrative territories reporting the rate at least 2 per 100,000 FORMTEXT FORMTEXT (M) = number of subnational administrative territories Viral detection in % (V) Target: ≥80% V = (P*100)/Q FORMTEXT % FORMTEXT (P) = number of chains of transmission of rubella for which adequate samples have been submitted for viral detection/genotyping FORMTEXT FORMTEXT (Q) = number of chains of transmission identified Viral detection for sporadic cases in % (V1) Target: ≥80% V =( p *100)/ q FORMTEXT % FORMTEXT ( p ) = number of sporadic cases from which samples were obtained and sequenced in an accredited laboratory FORMTEXT FORMTEXT ( q ) = number of sporadic cases * if possible, sporadic cases should be genotyped in countries that are approaching elimination or have already achieved elimination . Origin of infection identified in % (O) Target: ≥80% O = (W*100)/X FORMTEXT % FORMTEXT ( W ) = number of rubella cases for which the origin of infection (imported, import-related, endemic) has been identified FORMTEXT FORMTEXT (X) = total number of rubella cases Timeliness of investigation in % (I) Target: ≥80% I = (Y*100)/Z FORMTEXT % FORMTEXT (Y) = number of rubella cases with an adequate investigation FORMTEXT FORMTEXT (Z) = number of suspected rubella cases Alternative indicators – If the above standard indicators could be calculated using the available data, there is no need to provide alternative indicators. If data is not available to calculate the standard indicators, NVC should use these alternative indicators to assess the performance of measles surveillance. Indicator Value for indicator Numerator Denominator Remarks Timeliness of notification (in %; alternative to Timeliness and Completeness indicator) (Tn) Target: ≥80% Tn = ( CC *100)/ G FORMTEXT % FORMTEXT FORMTEXT (CC) = number of reports submitted within 48 hours FORMTEXT FORMTEXT ( G ) = number of suspected rubella cases Rate of cases tested negative for rubella IgM (alternative to Rate of Discarded Cases indicator) (N) Target: ≥2/100,000 N = ( DD *100,000)/J FORMTEXT /100,000 FORMTEXT FORMTEXT (DD) = number of negative IgM test results FORMTEXT FORMTEXT (J) = population Population immunity to measles and rubella Routine vaccination coverage of measles - and rubella - containing vaccines Summa ry of vaccination coverage, 20 2 1 – 2023 Routine vaccination coverage 1 202 1 202 2 202 3 Remarks Measles-containing vaccine, 1 st dose Measles-containing vaccine, 2 nd dose Rubella-containing vaccine, 1 st dose Rubella-containing vaccine, 2 nd dose 1 Vaccination coverage as in the official national routine immunization reports (JRF) . Methods used to determine the immunization coverage Please describe the methods by which routine immunization coverage is determined, including both numerator and denominator data. Please clearly indicate the source of population statistics. 1 st dose Description Source of data Comments Numerator Denominator 2 nd dose Description Source of data Comments Numerator Denominator Example : Numerator : Number of children &lt; 24 months of age that have received one dose of measles - and rubella - containing vaccine given after 12 months of age . Denominator : N umber of children 12-23 months of age Source of data : A dministrative reports from subnational level (annually updated) Additional data to determine the population immunity in 2023 Note: Additional data from rapid coverage monitoring, coverage surveys or seroprevalence studies, when available, should be included in the report. For published studies or final written reports, references may be appended to this report. Serological (S) or coverage (C) studies/surveys Targeted territory or subpopulation Results 1 2 3 Add /remove rows as needed Information of administrative territories with m easles/ r ubella-containing vaccine routine coverage 2023 Are there any administrative territories with less than 90% coverage for either first and/or second dose of m easles and/or r u bella-containing vaccine in 2023 ? (Please check the appropriate box) FORMCHECKBOX N o FORMCHECKBOX Y es (Please provide list of such territories in table below) FORMCHECKBOX Subnational coverage data are not collected or available FORMCHECKBOX No subnational administrative levels in the country Please list all administrative territories (subnational levels) with first and/or second dose coverage . Total number of subnational territories in the country in 2023 : FORMTEXT Territories Population size Coverage 1 st dose (%) Coverage 2 nd dose (%) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Add /remove rows as you need Information about h igh - risk population groups in the country Please indicate population groups with a higher than expected risk of developing/transmitting measles and/ or rubella due to insufficient level of vaccination coverage or known/possible measles or rubella transmission in the country of origin. Consider for example population groups for which vaccination coverage is influenced by religious beliefs or ethnic ity , residen ce in specific geographic or administrative areas, refugee or migrant status etc . Include high - risk groups here even though supplementary activities may have been implemented to improve coverage in these groups – these activities should be reported in the text box under 1.4.5 c. Q ualitative assessment of SIA . If details about these populations are not available, please note in the last column (Remarks) that your country is aware of the presence of these population groups. FORMCHECKBOX No high - risk population groups Description of high - risk population groups (please specify here) Estimated population size Estimated % of total population Estimated MR vaccination coverage Remarks Add /remove rows as you need Information on additional immunization activities in 2023 Actions taken to improve the level of immunization coverage in selected territories and/or in high - risk population groups in 2023 Text Supplemental immunization activities (SIA) Were supplementary immunization activities with measles/rubella – containing vac cine conducted in 2023 (please check the appropriate box)? FORMCHECKBOX YES FORMCHECKBOX NO If supplementary immunization activities were conducted , please summarize results in the table below and complete the SIA Technical Report form ( Section 4.3, one for each of SIA) SIA conducted as national or subnational Type of SIA (e.g. catch-up, mop-up, follow-up) Vaccine used (M, MR, MMR) Dates (start-end) (dd/mm/yyyy) Age range of target group Target population size Coverage achieved (%) Independent monitoring of SIAs is an objective measure of SIA quality. The SIA guidelines developed for injectable vaccines (using measles - and rubella -containing vaccines) can be used as a reference. These are available at http://www.who.int/immunization/diseases/measles/SIA-Field-Guide.pdf?ua=1,&amp;ua=1 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 SIA coverage was less than 90%. Text Section 2: Update of activities in country towards measles and rubella elimination Please indicate in the table below any programmatic changes related to measles, rubella and CRS that took place in your country in 2023 . Please describe ongoing or new activities in the country regarding CRS surveillance. Area of work Remarks Strategies ( considering national and WHO r egional strategies; any changes or new strategies introduced) I mmunization requirements and schedule, routine and supplemental Surveillance and reporting CRS - specific activities (ongoing and new) Other Section 3: Activities of the National Verification Committee (NVC) and its Secretariat Activities of the NVC in the year under review Please provide a brief summary of the NVC activities conducted in the year under review (you may extend your answer to include conducted and planned activities in the current year ) . Include key issues addressed , and list any concerns that have arisen (e.g. NVC concerns about the national programme, challenges in organizing and/or holding regular NVC meetings ) Activity Date (Month/Year) Highlights Challenges 1 2 3 Add /remove rows as you need The NVC Secretariat (list of national staff involved in preparation of ASU) Name Function in national health system* Position Organization Contact details (e-mail, tel . ) 1 2 3 4 5 Add/remove rows as you need * Key national public health experts who are responsible for or involved in operational aspects of immunization programme, surveillance, measles/rubella reference laboratory and other programme areas. Section 4 : Additional data on measles, rubella and CRS in 2023 Maps and epi curves with distribution of suspected and confirmed measles and rubella cases and measles and rubella outbreaks in 2023 The RVC has noted that the collection and submission of more detailed subnational data (graphs and maps , epi curves with suspected/confirmed cases, epi curves with different genotypes ) would facilitate the verification process. Therefore, if available (especially if already included in the routinely collected and analy s ed data) and feasible, please provide : M aps with distribution of confirmed and suspected measles and rubella cases by subnational administrative territories, preferably at the level of districts or equivalent basic administrative level (or a ny other territorial presentation of data) ; E pi - curves with distribution of cases ( time / place ) . Outbreak reports These can be as an attached document to email, as copy of the text into this form, as link to official document or web page, or other option convenient for you and accessible for RVC and its Secretariat. If it is technically challenging to insert them into this form, please send them as supplementary documents. T echnical report on SIA or ORI , if any conducted Please provide any report for supplemental immunization activities and outbreak response activities, if these were conducted in 2023. It can be in any format and language (preferable in official languages of the WHO Europe) . These can be as an attached document to email, as link to official document or web page, or other option convenient for you and accessible for RVC and its Secretariat. Annex 1 : WHO guiding documents and examples WHO Regional Office for Europe developed in 2023 the document “Eliminating measles and rubella in the WHO European Region Integrated guidance for surveillance, outbreak response and verification of elimination”, as update of previous guidelines. It will be in use from 2024. There are no significant changes in the instructions, but in any case, we are not planning to assess countries elimination and verification performance against the document that was not available in 2023. ASU for 2024 will be synchronized with the new guiding document . 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. Verification of regional elimination : 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 transmission : a chain of measles virus transmission that is continuous for ≥ 12 months within a country. To the greatest extent possible, this chain of transmission should be defined based on genotyping evidence along with epidemiological investigation. It is often the case that chains of transmission are unclear for measles, given the infectivity and mass movements of people. 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. Outbreak or chain of transmission : 2 or more measles or rubella cases which are temporarily related and epidemiologically or virologically linked, or both. 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. Note : According to “ Guidance for evaluating progress towards elimination of measles and rubella ”, Weekly epidemiological record, No. 41 , 201 8 , 93 , 541-552. ( https://apps.who.int/iris/bitstream/handle/10665/275392/WER9341.pdf?ua=1 ) Suspected case of measles or rubella – A patient in whom a health-care worker suspects measles or rubella infection, or a patient with fever and maculopapular (non-vesicular) rash . 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 12–23 days prior to onset of the disease. 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. Endemic case : Confirmed case of measles or rubella resulting from endemic transmission of measles or rubella. Imported case: a case exposed outside the country during the 7-18 days (measles) or 12-23 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). Unknown or igin case : A confirmed measles or rubella case for which no epidemiological or virological link to importation or endemic transmission can be established after a thorough investigation. 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. Genotype: Operational taxonomic unit defined on the basis of nucleotide variation between viral strains. Measles virus genotypes are defined on the genetic analysis of the N-450 sequence, which is the most variable region of the measles virus genome. Rubella virus genotypes are defined on genetic analysis of the E1- 739 sequence. MeaNS Distinct Sequence ID (measles only): is a 4-digit identifier assigned to a given N-450 sequence in MeaNS database, in addition to its unique identifiers (Sample ID and Sequence ID). All the identical N-450 sequences will harbour the same MeaNS Distinct Sequence ID, while having different Sample IDs and Sequence IDs. Some of the Distinct Sequence IDs will be assigned a named strain (see examples below). genotype, distinct seq ID and when available, named strains, are the data expected in tables 1.1.4.1 c and d . Named strain (measles only): Measles virus variant specifically identified in MeaNS as a representative N-450 sequence due to its important prevalence within the database (usually associated with widespread transmission). It allows describing viral diversity with finer resolution within a single genotype. Examples of named strains are shown below. MeaNS ID WHO name Genotype Distinct Seq ID Named Strain 139793 MVs/Derby.GBR/19.19/ B3 4298 MVs/Kabul.AFG/20.2014/3 144562 MVs/Reading.GBR/2.20/ B3 6254 no named strain for this Distinct Seq ID 144929 MVs/London.GBR/5.20/ D8 4683 MVs/Gir Somnath.IND/42.16/ 135047 MVs/Harrow.GBR/3.19/ D8 5676 no named strain for this Distinct Seq ID Case classification algorithm for measles and rubella ______________________________________________________________________________________ *Definitions are based on: Surveillance Guidelines for Measles, Rubella and Congenital Rubella Syndrome in the WHO European Region -Update December 2012 http://www.euro.who.int/__data/assets/pdf_file/0018/79020/e93035-2013.pdf?ua=1 Eliminating measles and rubella. Framework for the verification process in the WHO European Region http://www.euro.who.int/__data/assets/pdf_file/0009/247356/Eliminating-measles-and-rubella-Framework-for-the-verification-process-in-the-WHO-European-Region.pdf?ua=1 World Health Organization. Vaccine-preventable Diseases Surveillance Standard. Measles.2018 https://www.who.int/immunization/monitoring_surveillance/burden/vpd/WHO_SurveillanceVaccinePreventable_11_Measles_R2.pdf?ua=1 World Health Organization. Vaccine-preventable Diseases Surveillance Standard. Rubella. 2018 https://www.who.int/immunization/monitoring_surveillance/burden/vpd/WHO_SurveillanceVaccinePreventable_20_Rubella_R2.pdf?ua=1 Description of “Indicators and targets” for measuring performance of measles and rubella surveillance Indicator Description Target and Notes Timeliness of reporting (to national level) (T) Percentage of measles or rubella routine surveillance reports a submitted to the national level by the deadline b Target: ≥80% Example: A Number of reports submitted by the deadline B Number of expected reports T=(A*100)/B (%) Completeness of reporting (to national level) (C) Percentage of measles or rubella routine surveillance reports a submitted to the national level Target: ≥80% Example: E Number of submitted reports B Number of expected reports C=(E*100)/B (%) Rate of laboratory investigations (L) Percentage of cases suspected for measles or rubella with adequate specimens c collected and tested in a WHO accredited or 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 Target: ≥80% Example: F Number of suspected measles or rubella cases with ad equate specimens collected and tested in a proficient laboratory G Number of suspected cases L=(F*100)/G (%) Rate of discarded cases (D) The rate of suspected measles or rubella cases investigated and discarded as non-measles or non-rubella cases using laboratory testing in a proficient laboratory and/or epidemiological linkage to another confirmed disease Target: At least 2 discarded measles or rubella cases per 100 000 Example: H Number of suspected measles or rubella cases investigated and discarded as non- measles or non-rubella cases J Population D=(H*100 000)/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 100 000 population per year Target: ≥80% Example: K Number of subnational administrative territories reporting the rate of discarded cases (D) at least 2 per 100 000 population per year M Number of subnational administrative territories R=(K*100)/M (%) Viral detection (V) Percentage of laboratory-confirmed chains of transmission of measles or rubella with samples adequate for viral detection collected and tested in an accredited laboratory e Target: ≥ 80% Example: P Number of chains of transmission of measles or rubella for which adequate samples have been submitted for viral detection / genotyping Q Number of chains of transmission identified V=(P*100)/Q (%) Origin of infection identified (O) Percentage of measles or rubella cases for which the origin of infection (e.g. imported, import-related or endemic) has been identified Target: ≥ 80% Example: 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 O=(W*100)/X (%) Timeliness of investigation (I) Percentage of suspected measles or rubella cases with an adequate investigation f initiated within 48 hours of notification Target: ≥ 80% Example: Y Number of measles or rubella cases with an adequate investigation Z Number of suspected measles or rubella cases, respectively I=(Y*100)/Z (%) a Regular monthly or weekly reports, including “zero” reports to be submitted by each surveillance reporting unit to national level. This does not refer to lab reporting of cases. 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 Laboratory that is WHO accredited and/or has an established quality assurance programme with oversight by a WHO accredited laboratory . e M e asles a n d r u b e lla vi r u s es c a n b e de t e c t e d in nasal se c r eti o n s, urin e , s e r um a n d w h ol e b l oo d , a n d d r y b l oo d s p o t s u p t o se v e n d a y s a f t e r o n s e t o f t h e ras h a n d i n o r a l f l uid fo r e v en l o n g e r . 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 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) 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 Target: ≥80% Example: CC Number of reports submitted within 48 hours G Number of suspected cases Tn=( CC *100)/ G (%) Rate of cases tested negativ e for measles or rubella IgM (N ) Alternative to Rate of discarded cases The rate of cases of measles or rubella-like illnesses (MLI/RLI) whose specimens tested IgM nega tive in a proficient laboratory Target: At least 2 MLI/RLI cases tested negative per 100 000 population (nationwide) Example: DD Number of measles or rubella cases tested negative for measles or rubella IgM J Population N=( DD *100 000)/ J Sustaining measles and rubella elimination after verification - Discussion points for NVC and its Secretariat on risk for re-establishing endemic transmission of diseases C ountries verified by the RVC as having achiev ed interruption of endemic measles and rubella transmission for a period of 36 months should assess their risks for re-establishing endemic transmission of diseases. Recognizing that the risk of importation will exist as long as measles and rubella viruses are present and circulating in other countries, each national public health system’s priorities are high immunity of the population, sensitive surveillance system and established conditions and capacities for prompt and comprehensive outbreak response. Below is a list of possible challenges and suggestions for sustaining elimination status , developed based on recognized and reported situations in countries. It is not a comprehensive list of all issues and it is not intended to be used as a tool with measurable indicators or thresholds . W e expect that t he National Verification Committee and national technical staff ( the NVC’s Secretariat) will use it to review whether these challenges are present in the country ; whether they are recognized and being addressed, or whether there is a plan to address them ; and what role the NVC can play or is playing in supporting the national public health system dealing with these issues , with expected technical inputs from and involvement of the national technical advisory bodies and structures. Immunity/susceptibility of population National immunization programme performance in recent years and routine i mmunization coverage Monitor rates and trends related to coverage , timelines of immunization (according to age-specific recommendation s ), and potential variation in coverage per vaccine dose ( due to implementation, availability, acceptance or other reasons ) with first and/or second dose. Define the most affected by suboptimal coverage or downward trends (e.g. territories, populations, minorities/ethnic groups, social-economic group s ) . Clarify the main reasons for this situation, list ongoing and planned activities to deal with this situation and discuss further and additional steps (benefits of intervention in policy segment, influencing decision - makers, or addressing the public) to reach/ keep coverage at 95% or higher with both doses . Susceptible population among adolescents and adults Review a vailab le d ata or estimat e the size of the susceptible population among adolescent and adults (not immunized or immunized with just one dose due to absence of immunization programme, different requirements and schedule , gaps in vaccine supply) and any supplemental immunization activity taken or planned (army service, university entry requirements, for specific occupations or work in health and educational system, for international travel etc.) Review p ossibility of aggregation of susceptible individual s or possible increased contacts among susceptible individuals due to social or family relations (economic migration, education institutions, family of susceptible adults and newborn s , parents and children contacts in kindergartens ). Review i nternal (inside country) migration and moving of susceptible individual s (countries with historical difference in immunization programme for different territories, or with different coverage at different subnational territories). Identify the p roportion of adolescents and adults who are born in other countries and who were immunized according to immunization programme s of th ose countr ies , and review their immunization programmes ( coverage may be higher or lower, immunization and two-dose schedule introduced earlier or later than in your country) . Specific subgroups of population with low immunization coverage or that are not immunized Identify a ll such groups and the reasons for their low immunization coverage (access, denial, refusal, poor services) . Have adequate steps and strategies to address their needs been taken , or planed ? If needed, plan additional activities to better define these groups and the best approach to increase their coverage . Surveillance High sensitivity of health care system/health care workers to measles/rubella/CRS in absence of diseases Check whether h ealth care workers ( HCW ) are trained and systematically reminded to stay vigilant and suspect measles/rubella/CRS, through diseases-specific reporting, or syndromic surveillance, or as part of programmes for surveillance and reporting of congenital malformation. If some challenges are recognized, check whether specific action s are conducted and plan n ed, and if not , plan for actions to be discussed. Adequate quality of surveillance Assess r eliability and adequacy of diseases surveillance against global measles and rubella surveillance indicators . If global surveillance indicators are not implementable or are incompatible with the current health system structure and procedures, other indicators should be considered in order to assess quality of surveillance. A high-quality surveillance is the one that have every suspected case of measles, rubella and CRS (appearing anywhere in the country during the year ) reported, investigated and confirm or discard . Ensure that a ll segments of surveillance (clinical, epidemiological and laboratory) are coordinated and cooperate , and that every suspected case is investigated adequately and timely to identify details of genotype and lineages of the viruses. Ensure that s urveillance data are systematically used and analy s ed to detect and define susceptible individuals and groups , and that adequate measures to immunize them are taken/planned . Outbreak response Ensure that l essons learn ed from previous outbreaks are /will be used to improve outbreak response . Check that a ll stakeholders understand that an outbreak is an emergency and its control is a high priority . Check that a ll requirements for adequate, timely response are in place , including l egislation allo wing timely intervention ; up to date technical guidelines and protocols ; health care workers and all other critical participants in outbreak response are trained and aware of their role and responsibility; s ufficient resources (financial, human , vaccine, logistics) are or can quickly become available in short period , prepared and trained a dvocacy and communication teams who have developed materials, messages and tailored ways of communication (different for different target population s ) ; planned and prepared c ooperation with partners (governmental sectors, private sector, NGOs, donors, media) . Use o utbreak analysis systematically to define susceptible individual s and undertake adequate measures to immunize them to prevent similar events in future .