Vaccine xxx (2018) xxx–xxx

Contents lists available at ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Global landscape of measles and rubella surveillance

Minal K. Patel a,⇑, Randie Gibson a,b, Adam Cohen a, Laure Dumolard a, Marta Gacic-Dobo a
a
Expanded Programme on Immunization, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
b
School of Public Health, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Background: All six World Health Organization (WHO) regions have committed to eliminate measles, and
Received 20 March 2018 three WHO regions have committed to eliminate rubella. One of the key tenets of measles and rubella
Received in revised form 7 August 2018 elimination is to have a strong surveillance system in place. The presence of a case-based measles and
Accepted 1 October 2018
rubella surveillance system that is national, population-based, provides laboratory confirmation, and
Available online xxxx
directs action, is one of the requirements for elimination-standard surveillance.
Methods: In order to understand the global landscape for measles and rubella surveillance, a question-
Keywords:
naire was sent to all 194 WHO member states (herein referred to as countries) requesting information
Measles
Rubella
on how surveillance was conducted for measles, rubella, and congenital rubella syndrome. Data were
Surveillance supplemented with information provided to WHO through other reporting mechanisms and by national
Elimination policy documents available to the public. Frequencies and percentages were calculated.
Results: Data were available to review from 164 (85%) countries, although not every country responded
to every question. Case-based, population-based, national surveillance with laboratory confirmation was
reported to be conducted in 136 (86%) of 158 countries for measles and 122 (77%) of 158 countries for
rubella. Congenital rubella syndrome surveillance was reported to be conducted by 126 (77%) of 163
countries. Gaps were noted in the quality of measles-rubella surveillance conducted, and 26 (16%) of
158 countries reported not including all healthcare providers as mandatory reporters.
Conclusions: Many countries reported having some of the essential components in place to conduct
elimination-standard surveillance for measles and rubella; however, in order to achieve elimination,
the quality of surveillance needs to improve to detect all cases. In those countries without these essential
components of elimination-standard surveillance, the first step is to implement these components.
Ó 2018 Published by Elsevier Ltd.

1. Introduction Elimination-standard surveillance is a case-based surveillance sys-

The Global Vaccine Action Plan calls for measles and rubella
elimination in five World Health Organization (WHO) regions by
2020 [1]. To date, all six WHO regions have committed to eliminate
measles by 2020, and three regions, the Americas, European, and
Western Pacific regions, have rubella elimination goals [2]. The
Strategic Advisory Group of Experts on Immunization established
a framework for verification of elimination of measles and rubella;
the presence of high-quality surveillance is one of three criteria
required for verification of elimination [3]. Furthermore, it is rec-
ommended that measles and rubella surveillance be integrated
[3,4]. Thus, every country should have a platform capable of con-
ducting elimination-standard measles and rubella surveillance.
⇑ Corresponding author.
E-mail addresses: patelm@who.int (M.K. Patel), r.gibson@usask.ca (R. Gibson),
cohena@who.int (A. Cohen), dumolardl@who.int (L. Dumolard), gacicdobom@who.
int (M. Gacic-Dobo).
tem (defined as a system that collects information on each case at
the individual level [5]) that in a timely manner can detect cases,
notify public health officials, investigate suspected cases rapidly,
classify cases as confirmed or discarded, and respond rapidly to
prevent further transmission of disease. Some essential compo-
nents of elimination-standard surveillance include having a case-
based surveillance system that provides laboratory confirmation
throughout the entire country (national), and can detect cases
among everyone living in the country (population-based). Having
these specific components is the foundation for achieving
elimination-standard measles and rubella surveillance, although
having these components alone does not guarantee elimination-
standard surveillance. Surveillance system indicators have been
defined to assess the quality of a measles-rubella surveillance sys-
tem and provide evidence that a country has achieved elimination-
standard surveillance, although not every indicator is applicable to
every country [3,4].

https://doi.org/10.1016/j.vaccine.2018.10.007
0264-410X/Ó 2018 Published by Elsevier Ltd.

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2 M.K. Patel et al. / Vaccine xxx (2018) xxx–xxx

WHO has provided guidance on surveillance in elimination set-
tings for measles, rubella, and congenital rubella syndrome (CRS)
[3,6]. WHO regions adapted this global guidance based on specific
regional settings; specifically, case definitions and recommenda-
tions on the algorithm for laboratory testing were adjusted based
on resources and progress towards elimination [7–12]. Table 1 out-
lines the global and regional recommendations for conducting
measles-rubella surveillance.
Almost all countries conduct measles and rubella surveillance
and report surveillance data to WHO regularly (either weekly or
monthly). At the global level, WHO collects monthly data on the
number of reported measles and rubella cases; however, little is
known at a global level about how surveillance is actually being
conducted in each country. To understand the global situation
and how much variability in measles and rubella surveillance
exists, a survey was conducted to determine if countries follow
the recommended global and/or regional standards for measles
and rubella surveillance.
nents of an elimination-standard surveillance platform, namely if
the system (1) was case-based, (2) had the ability to laboratory
confirm cases, (3) was national, and (4) was population-based.
These four components are necessary but not sufficient for measles
and rubella elimination-standard surveillance. The data provided
by countries were reviewed, and countries were asked to clarify
and correct discrepancies that were identified. Data on measles
and rubella surveillance systems were supplemented by reviewing
other sources of information provided to the public through official
government websites or to WHO. Additional data sources included
annual measles verification reports provided to WHO as part of the
regional measles verification process for countries in WHO’s Euro-
pean and South-East Asia Region, national surveillance guidelines,
and the WHO/UNICEF Joint Reporting Form. Data were stored and
analyzed using Microsoft Excel 2010 (Seattle, WA, USA), and the
results were mapped using ArcGIS 10.5 (Redlands, CA, USA).
2.2. Measles-Rubella surveillance system indicators

2. Methods Using the monthly country data reported to WHO as of Decem-

2.1. Surveillance system characteristics
In 2017, WHO disseminated an electronic questionnaire about
surveillance to all 194 member states (hereinafter referred to as
countries) as part of the WHO-United Nations Children’s Fund
(UNICEF) Joint Reporting Process [13]. The Joint Reporting Form
is a standardized questionnaire that is distributed annually to all
countries to gather information on vaccination programs and dis-
ease burden. The supplemental questionnaire distributed in 2017
asked about the current status of surveillance for 28 diseases
which are currently, or will in the future be, classified as vaccine-
preventable diseases (VPDs). Questions also asked about attributes
of surveillance conducted for each VPD and details about the cur-
rent measles, rubella, and CRS surveillance system(s) in each coun-
try. For measles and rubella surveillance, this snapshot only
focused on collecting information on some of the essential compo-
ber 8, 2017, the incidence of measles per million persons was cal-
culated for each country by dividing the cumulative number of
laboratory-confirmed, epidemiologically-linked, and clinically-
compatible cases from July 2016 to June 2017, by the country-
specific total population obtained from the 2017 Revision of World
Population Prospects [14]. High burden countries were defined as
those that had >5 measles cases per million persons; low burden
countries were defined as those that had 5 cases per million per-
sons. If data were provided to WHO on the number of discarded
cases, the rate of discarded non-measles non-rubella cases at the
national level, which is a proxy for sensitivity of the measles-
rubella surveillance system, was calculated by country from July
2016 to June 2017 [3]. Countries achieving a national discard rate
of 2/100,000 persons were defined as having achieved adequate
sensitivity; countries with a national discard rate of <2/100,000
persons were defined as having poor sensitivity of the measles-
rubella surveillance system.

Table 1
Recommendations for case definitions and laboratory algorithm for measles and rubella.

Geographic Area
Global [3]
Region of the Americas [9]
Africa Region [8]
Eastern Mediterranean
Region [10]
European Region [7]
South-East Asia Region [11]
Western Pacific Region [12]
a
Serial testing is defined as measles antibody being tested first, with samples testing negative for measles antibody being tested for rubella antibody, or vice versa, based
on disease incidence. Parallel testing is where all samples are tested for both measles and rubella regardless of results.
Number of Suspected Measles Case Definition Suspected rubella case definition Recommended laboratory
Countries algorithma
194 Fever and maculopapular rash Fever and maculopapular rash Based on incidence, with
OR OR integrated testing (serial or
Suspected by a Healthcare worker Suspected by a Healthcare worker parallel testing)
35 Fever and maculopapular rash Fever and maculopapular rash Parallel testing
OR OR
Suspected by a Healthcare worker Suspected by a Healthcare worker
47 Fever and maculopapular rash and one of Fever and maculopapular rash and one of Serial testing
the following: cough, conjunctivitis, the following: cough, conjunctivitis, coryza
coryza (3 C’s) (3 C’s)
OR OR
Suspected by a Healthcare worker Suspected by a Healthcare worker
21 Fever and maculopapular rash and one of Suspected to be rubella by a Healthcare Serial testing
the following: cough, conjunctivitis, worker
coryza (3 C’s)
53 Fever and maculopapular rash and one of Maculopapular rash and cervical, Based on incidence, with
the following: cough, conjunctivitis, suboccipital, or postauricular adenopathy, integrated testing (serial or
coryza (3 C’s) or arthralgia/arthritis parallel testing)
11 Fever and maculopapular rash Fever and maculopapular rash Serial testing
OR OR
Suspected by a Healthcare worker Suspected by a Healthcare worker
27 Fever and maculopapular rash Fever and maculopapular rash Based on incidence, with
integrated testing (serial or
parallel testing)

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vaccine.2018.10.007
 M.K. Patel et al. / Vaccine xxx (2018) xxx–xxx
2.3. Analysis
Frequencies and percentages were calculated for each variable,
and comparisons were made to the global and regional guidelines
for specific components. Rubella-specific analysis was stratified by
whether or not the country belonged to a region with a rubella
elimination goal. Achievement of the recommended discard rate
was reviewed only for those countries that reported having the
specific essential components of elimination-standard surveillance
as described above.
3. Results
Of the 194 eligible countries, 130 (67%) responded to the ques-
tionnaire and an additional 34 (18%) had data collected from other
sources, for a total of 164 (85%) countries having some data on
measles, rubella, or CRS surveillance. However, not every country
responding to the survey responded to every question in the
survey.
3.1. Measles-Rubella surveillance system attributes
All 164 countries reported conducting surveillance for measles
and rubella (Figs. 1A and 1B). Case-based, population-based,
national surveillance with laboratory confirmation was reported
to be conducted in 136 (86%) of 158 countries for measles and
122 (77%) of 158 countries for rubella; six countries were excluded
from the denominator as data were not available to analyze. Only
three (2%) countries reported not conducting measles surveillance
to this standard, while seven (4%) reported not conducting rubella
surveillance to this standard. Nineteen (12%) countries did not pro-
vide sufficient information on measles and 29 (18%) on rubella to
categorize whether they had these specific essential components
of elimination-standard surveillance. From the global population
perspective, at least 85% of the world’s population lived in a coun-
try conducting case-based, population-based, national measles
surveillance with laboratory confirmation, and at least 80% of the
Fig. 1A. Presence of a case-based, population-based, national measles surveillance system with laboratory confirmation (‘‘recommended measles surveillance system”).
Please cite this article in press as: Patel MK et al. Global landscape of measles and rubella surveillance. Vaccine (2018), https://doi.org/10.1016/j.
vaccine.2018.10.007
3
world’s population lived in a country conducting case-based,
population-based, national rubella surveillance with laboratory
confirmation. For both measles and rubella, Mauritius did not have
the essential components of elimination-standard surveillance
because it reported conducting aggregate surveillance instead of
case-based surveillance; the Solomon Islands and Afghanistan
reported conducting sentinel site surveillance instead of
population-based surveillance. For rubella alone, Belgium, Den-
mark, and France reported that surveillance was only conducted
among pregnant women and not the entire population, while Palau
reported conducting sentinel surveillance instead of population-
based surveillance. Among 97 countries with data in those regions
with a rubella elimination goal, 82 (85%) reported having case-
based, population-based, national rubella surveillance with labora-
tory confirmation. Among 61 countries with data in those regions
without a rubella elimination goal, 40 (66%) reported having case-
based, population-based, national rubella surveillance with labora-
tory confirmation.
Of the 136 (86%) countries that reported having the four specific
essential components for measles elimination-standard surveil-
lance, 94 (69%) had data allowing calculation of a non-measles
non-rubella discard rate. Only 46 (49%) of these 94 countries
achieved the 2/100,000 non-measles non-rubella discard rate
(Fig. 2). One hundred and twenty-two (77%) countries reported
having the four specific essential components for rubella
elimination-standard surveillance. Of these 122 countries, only
82 (67%) countries had data where a non-measles non-rubella dis-
card rate could be calculated; only 41 (50%) of these 82 countries
achieved the 2/100,000 non-measles non-rubella discard rate
(Fig. 2).
3.2. Measles-Rubella surveillance system details
Of 160 countries, 54 (34%) reported using the globally-
recommended case definition ‘‘a person with fever and
maculopapular rash” for a suspected measles case (Tables 2A).
Ninety-seven (61%) of 160 countries reported using the more
4 M.K. Patel et al. / Vaccine xxx (2018) xxx–xxx

Fig. 1B. Presence of case-based, population-based, national rubella surveillance system with laboratory confirmation (‘‘recommended rubella surveillance system”).

Fig. 2. Non-measles non-rubella discard rate per 100,000 persons, July 2016-July 2017.

specific case definition (‘‘a person with fever and maculopapular
rash and one of cough, coryza or conjunctivitis”); this more specific
case definition was used during the mortality reduction phase of
measles. Similar findings were reported for rubella surveillance;
55 (35%) of 160 countries reported using the globally-
recommended case definition for a suspected rubella case (‘‘a per-
son with fever and maculopapular rash”), while 74 (47%) of 160
countries reported using the specific definition of ‘‘a person with
maculopapular rash and cervical, suboccipital or postauricular
lymphadenopathy, or arthralgia/arthritis” (Table 2B). ‘‘Suspicion

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vaccine.2018.10.007
 M.K. Patel et al. / Vaccine xxx (2018) xxx–xxx 5

Table 2A
Number and percentage of countries reporting the suspected measles case definition used, by region. The gray shading highlights the case definition(s) recommended in each
region.

a
Healthcare worker suspicion and other could not always be extracted from supplemental data sources, thus resulting in the changing denominator.

by a health care worker (HCW)” was included in the suspected case
definition in 60 (46%) of 160 countries for measles and 50 (38%) of
160 countries for rubella.
One hundred and forty-four (95%) of 152 countries reported
having mandatory reporting for all suspected measles cases, and
121 (79%) of 153 reported having mandatory reporting for all sus-
pected rubella cases. Eight countries did not have mandatory
reporting of either, while 21 countries had mandatory reporting
of suspected measles cases but not of suspected rubella cases.
Among 92 countries with data in those regions with a rubella elim-
ination goal with data, 76 (83%) had mandatory rubella reporting,
compared to 45 (74%) of 61 countries with data in those regions
without an elimination goal. One hundred and thirty-four (89%)
of 151 countries required reporting of measles to be done at least
on a weekly basis. Among the WHO regions, the Western Pacific
region had the lowest proportion (10/16, 63%) of countries requir-
ing measles to be reported weekly or more frequently.
One hundred and twenty-seven (80%) of 158 countries reported
that all health facilities and healthcare providers, including all pri-
vate and public-sector health care facilities, were part of case-
based, national surveillance for measles and rubella. Of 26 (16%)
countries that reported not including all providers, 25 reported
excluding private facilities, while seven reported excluding some
public health facilities, usually those where health facilities are
challenging to access (e.g., three are island countries with hard-
to-reach health facilities).
Most countries reported following the regional or global recom-
mendations for laboratory testing of suspected measles and rubella
cases, although significant variation existed. Of 157 countries pro-
viding data on laboratory testing, 69 (44%) reported conducting
serial testing driven in large part by incidence of disease (namely,
testing first for measles, and then for rubella if the sample was
measles IgM antibody negative, or testing first for rubella and then
for measles if the sample was rubella IgM antibody negative).
Seventy-one (45%) countries reported conducting parallel testing
(that is, testing all samples for both measles and rubella simultane-
ously irrespective of the result); 32 (20%) countries reported only
conducting testing based on the clinician’s request, i.e., samples
from suspected measles cases are only tested for measles, and
those from suspected rubella cases are only tested for rubella. Test-
ing based on the clinician’s request was most frequent in the Euro-
pean region in which 23 (44%) of 52 European countries providing

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6 M.K. Patel et al. / Vaccine xxx (2018) xxx–xxx

Table 2B
Number and percentage of countries reporting the suspected rubella case definition used, by region. The gray shading highlights the case definition(s) recommended in each
region.

a
Healthcare worker suspicion and other could not always be extracted from supplemental data sources thus resulting in the changing denominator.

data followed this practice. While most parallel testing occurred in
countries with a low incidence of measles, 12 (8%) countries with
an incidence of >5 cases of measles per million persons performed
parallel testing. This does not conform to the global recommenda-
tion for high burden countries to perform serial testing based on
incidence to save limited resources.
Among 61 countries with data in those regions without a rubella
elimination goal, 26 (43%) countries did not have CRS surveillance,
and 18 (30%) had case-based surveillance with laboratory confir-
mation that was either national and population-based or sentinel.
4. Discussion

3.3. CRS surveillance High-quality elimination-standard surveillance is crucial to

CRS surveillance was reported to be conducted by 126 (77%) of
163 countries (Fig. 3). Of these, 76 (60%) reported conducting
national, population-based, case-based surveillance with labora-
tory confirmation. Eighteen (14%) countries reported conducting
case-based sentinel surveillance with laboratory confirmation.
Thirty-two (20%) countries did not provide sufficient information
on the type of surveillance being undertaken for CRS to categorize
them as having national population-based or sentinel, case-based
surveillance with laboratory confirmation, or they reported con-
ducting surveillance not conforming to the global recommendation
(e.g., aggregate surveillance, lack of laboratory confirmation).
Among 102 countries with data in those regions with a rubella
elimination goal, 11 (11%) countries did not have CRS surveillance,
and 76 (75%) had case-based surveillance with laboratory confir-
mation that was either national and population-based or sentinel.
documenting that measles and rubella elimination has been
achieved. In 2016, the Measles and Rubella Global Strategic Plan
2012–2020, Midterm Review identified one of the biggest gaps in
progress towards elimination as being adequate surveillance [15].
This manuscript provides a previously unavailable understanding
of the current global status of measles, rubella, and CRS surveil-
lance. We found that most, but not all, countries providing data
for this survey had four specific, but essential, components (case-
based, national, population-based, with laboratory confirmation)
of elimination-standard surveillance; however, the non-measles
non-rubella discard rate of some of these surveillance systems is
below globally-established standards. A low discard rate is a surro-
gate for poor sensitivity of the measles-rubella surveillance sys-
tem. It is reassuring to see that the basic foundation for measles
and rubella surveillance is in place, but these countries failing to
meet the globally-recommended discard rate need to improve

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 M.K. Patel et al. / Vaccine xxx (2018) xxx–xxx
Fig. 3. Type of Congenital Rubella Syndrome (CRS) surveillance system in place.* (*‘‘Unknown surveillance” is defined as a country that reported doing CRS surveillance, but
the details on how surveillance was done was not provided. ‘‘Data not available” means that data were not provided by a country on if they do or do not conduct CRS
surveillance.)
their surveillance system quality. Furthermore, even though it is
recommended that measles and rubella surveillance be integrated,
there are some countries that have yet to do this. In addition, CRS
surveillance is lagging behind rubella disease surveillance, with
23% of countries not conducting CRS surveillance. CRS surveillance
is needed to help provide evidence that rubella has been
eliminated.
The Roadmap to elimination standard measles and rubella surveil-
lance describes practical steps on how countries can improve
surveillance quality and achieve all the components needed for
elimination-standard surveillance [4]. Some countries reported
having some of the necessary components to conduct
elimination-standard surveillance, although several variations
were identified, particularly in countries in regions without rubella
elimination goals. In those countries without the four specific com-
ponents of elimination-standard measles-rubella surveillance,
efforts should be made to ensure that surveillance is national,
population-based, case-based, with laboratory confirmation. All
public and private health facilities must be involved in surveillance
to ensure that all cases are identified, reported, and responded to
appropriately-and that this is done in a timely fashion.
Most countries were following the suspected case definition of
their region. Ideally, case definitions should be aligned with global
case definitions to help prepare for eradication. Countries using the
more specific case definition of ‘‘a person with fever and macu-
lopapular rash and cough, coryza, or conjunctivitis” are probably
missing some measles cases since the symptoms are not found in
all of confirmed measles cases and many rubella cases since these
symptoms are specific for measles and not rubella [16]. This, along
with variable surveillance quality, makes the comparison of dis-
ease burden between countries challenging. The globally-
recommended suspected case definition of ‘‘a person with acute
fever and rash” along with healthcare worker suspicion is extre-
mely sensitive but not specific, with the goal of ensuring that no
measles case is missed. One way in which some countries can
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vaccine.2018.10.007
7
improve their surveillance quality is to change to the more sensi-
tive case definition. However, many countries do not have the
resources to test every acute fever-and-rash case, and, with the
success of immunization, measles is becoming rare in many places.
Given this, countries will have to consider the quality and perfor-
mance of their surveillance systems, but, at a minimum, need to
ensure that their health systems can rapidly identify all measles
and rubella cases. One tactic that is recommended, given the broad
case definition, is to integrate measles and rubella surveillance
with other febrile rash surveillance systems (e.g., dengue). Practi-
cally speaking, this means that all diseases of public health impor-
tance with a febrile rash presentation are investigated
simultaneously and tested for from one laboratory specimen. This
allows for more efficient use of resources both in the laboratory
and during case investigations, and, in low incidence settings
where clinicians might not be thinking about measles and/or
rubella, it ensures that cases are still able to be detected.
Measles and rubella surveillance is facing an impending chal-
lenge. Currently, much of measles and rubella surveillance relies
on polio surveillance systems [17,18]. With polio nearing eradica-
tion, polio resources are diminishing, which will threaten already
inadequate measles and rubella surveillance systems. This is espe-
cially true in countries with the highest measles burden as these
countries rely most heavily on polio surveillance infrastructure.
Countries and stakeholders must recognize that high quality
elimination-standard measles and rubella surveillance is vital to
achieving measles and rubella elimination. Given limited
resources, high burden countries should use laboratory algorithms
based on measles and rubella incidence to save money and reduce
unnecessary testing.
This evaluation has important limitations. In the supplemental
questionnaire distributed in 2017, only a few questions were asked
about elimination-standard surveillance; these questions per-
tained to foundational elements only. There are many attributes
which need to be in place to meet elimination-standard surveil-
8 M.K. Patel et al. / Vaccine xxx (2018) xxx–xxx
lance that were not able to be assessed by this questionnaire—for
example, the ability to detect cases quickly, the ability to conduct
thorough investigations on every case to understand who is
infected as well as where and why the person in question was
infected, and the use of the data to inform the program and prevent
future cases from occurring. Not every country had data available,
with a noticeable gap in the Eastern Mediterranean Region (only
50% of countries in this region had data available to analyze). Data
collected from the surveillance questionnaire included self-
reported data at the country level. The data should be interpreted
with the understanding that some responses may be incorrect or
incomplete depending on the individual survey respondent’s
knowledge and his or her interpretation of the questions. Addition-
ally, national recommendations and policies reported may not
accurately reflect actual surveillance practices in the country.
Finally, we considered a country as having a high quality surveil-
lance system for measles and rubella if it met the globally-
recommended discard rate, although high quality surveillance
has a number of other components which were not analyzed here
[3]. Failing to meet the discard rate also does not necessarily mean
that surveillance is not high quality, as some countries have
surveillance systems which are unable to capture the suspected
cases of measles and rubella for which samples are IgM antibody
negative, and therefore a discard rate cannot be calculated.
This survey provided insight into the variability that exists
among the measles and rubella surveillance systems and improves
our understanding of where to target improvements to achieve
measles and rubella elimination. The next steps needed by coun-
tries and other measles and rubella elimination stakeholders are
to improve the quality of surveillance being conducted among
those countries with the foundation for elimination-standard
surveillance. Among those countries not conducting case-based
nationwide population-based surveillance with laboratory confir-
mation, the surveillance system must be expanded to include these
characteristics. Rubella and CRS surveillance is less well-developed
than measles surveillance, and those countries without a rubella or
CRS surveillance system in place should work to establish one.
Acknowledgements
We would like to thank countries for taking the time to provide
data, and WHO staff who were instrumental in obtaining the data
and helping to improve the quality of the data provided. We would
also like to thank the Canadian Institutes of Health Research and
the Public Health Agency of Canada for supporting R. Gibson
through the Dr. James Rossiter MPH Practicum Award.
Conflict of interest
None.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Disclaimer
The boundaries and names shown and the designations used on
these maps do not imply the expression of any opinion whatsoever
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vaccine.2018.10.007
on the part of the World Health Organization concerning the legal
status of any country, territory, city or area or of its authorities, or
concerning the delimitation of its frontiers or boundaries. Dotted
and dashed lines on the maps represent approximate border lines
for which there may not yet be full agreement. Ó WHO 2018. All
rights reserved.
References
[1] World Health Organization. Global Vaccine Action Plan, 2011–2020. Geneva,
Switzerland: World Health Organization; 2013. <http://www.who.int/iris/
bitstream/10665/78141/1/9789241504980_eng.pdf?ua=1> [accessed:
September 5, 2017].
[2] Global vaccine action plan: monitoring, evaluation, and accountability.
secretariat annual report 2016. Geneva, Switzerland: World Health
Organization; 2016. <http://www.who.int/immunization/global_vaccine_
action_plan/gvap_secretariat_report_2016.pdf?ua=1> [accessed: September
5, 2017].
[3] Surveillance standards for vaccine-preventable diseases, 2nd ed. Geneva: World
Health Organization; 2018. <http://www.who.int/immunization/monitoring_
surveillance/burden/vpd/standards/en/> [accessed: October 9, 2018].
[4] Sniadack DH, Crowcroft NS, Durrheim DN, Rota PA. Roadmap to elimination
standard measles and rubella surveillance. Wkly Epidemiol Rec
2017;92:97–105.
[5] Murray J, Cohen AL. Infectious disease surveillance. In: Quah SR, Cockerham
WC, editors. International encyclopedia of public health. Oxford: Academic
Press; 2017. p. 222–9.
[6] World Health Organization. Introducing Rubella vaccine into the National
Immunization Programmes: a step-by-step guide. Geneva, Switzerland: World
Health Organization; 2015. <http://apps.who.int/iris/bitstream/handle/10665/
184174/9789241549370_eng.pdf;jsessionid=E170550AEFB34D93640A3440D
320564B?sequence=1> [accessed: May 2, 2018].
[7] World Health Organization European Region. Surveillance Guidelines for
Measles, Rubella, and Congenital Rubella Syndrome in the WHO European
Region. Copenhagen, Denmark; 2012. <http://www.euro.who.int/__data/
assets/pdf_file/0018/79020/e93035-2013.pdf?ua=1> [accessed: September 5,
2017].
[8] World Health Organization: Regional Office for Africa. African Regional
Guidelines for Measles and Rubella Surveillance. Brazzaville, Republic of
Congo; 2015. <http://www.afro.who.int/sites/default/files/2017-06/who-
african-regional-measles-and-rubella-surveillance-guidelines_updated-draft-
version-april-2015_0.pdf> [accessed: September 5, 2017].
[9] Pan American Health Organization. Measles Elimination Field Guide. 2nd ed.
Washington, D.C., USA; 2005. <http://www1.paho.org/hq/dmdocuments/
2010/FieldGuide_Measles_2ndEd_e.pdf> [accessed: September 5, 2017].
[10] World Health Organization Regional Office for the Eastern Mediterranean.
Field guidelines for surveillance of measles, rubella, and congenital rubella
syndrome. Cairo, Egypt; 2011. <http://applications.emro.who.int/dsaf/
emropub_2011_1261.pdf> [accessed: September 5, 2017].
[11] World Health Organization: Regional Office for South-East Asia. Surveillance
Guide for Vaccine-Preventable Diseases in the WHO South-East Asia Region
(DRAFT). New Delhi, India; 2017 [accessed].
[12] World Health Organization: Regional Office for the Western Pacific Region.
Measles Elimination Field Guide. Manila, Philippines; 2013. <http://www.
wpro.who.int/entity/immunization/documents/measles_elimination_field_
guide_2013.pdf?ua=1> [accessed: September 5, 2017].
[13] World Health Organization. WHO/UNICEF Joint Reporting Process; 2018.
<http://www.who.int/immunization/monitoring_surveillance/routine/
reporting/reporting/en/> [accessed].
[14] United Nations. World Population Prospects 2017; 2017. <https://esa.un.org/
unpd/wpp/> [accessed].
[15] Orenstein WA, Hinman A, Nkowane B, Olive JM, Reingold A. Measles and
Rubella Global Strategic Plan 2012-2020 Midterm Review. Geneva,
Switzerland; 2016. <http://www.who.int/immunization/sage/meetings/2016/
october/1_MTR_Report_Final_Color_Sept_20_v2.pdf?ua=1> [accessed:
September 5, 2017].
[16] Hutchins SS, Papania MJ, Amler R, Maes EF, Grabowsky M, Bromberg K, et al.
Evaluation of the measles clinical case definition. J Infect Dis 2004;189(Suppl
1):S153–9.
[17] Wassilak SGF, Williams CL, Murrill CS, Dahl BA, Ohuabunwo C, Tangermann
RH. Using acute flaccid paralysis surveillance as a platform for vaccine-
preventable disease surveillance. J Infect Dis 2017;216:S293–8.
[18] Kretsinger K, Strebel P, Kezaala R, Goodson JL. Transitioning lessons learned
and assets of the global polio eradication initiative to global and regional
measles and rubella elimination. J Infect Dis 2017;216:S308–15.