Technical Appendix

World Health Organization

Measles Programmatic Risk Assessment Tool

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1. Summary of the World Health Organization Measles
Programmatic Risk Assessment Tool
The World Health Organization Measles Programmatic Risk Assessment Tool identifies
areas not meeting measles programmatic targets in order to guide and strengthen measles
elimination program activities and reduce the risk of outbreaks. The Risk Assessment Tool
assesses subnational programmatic risk as the sum of indicator scores in four categories:
population immunity, surveillance quality, program performance, and threat assessment.
Each district in a country is assigned to a programmatic risk category of low, medium, high,
or very high risk based on the overall risk score. Scoring for each indicator score was
developed based on expert consensus.

 Population immunity: Assesses measles susceptibility using administrative

vaccination coverage data for first-dose (MCV1) and second-dose (MCV2) measles-
containing vaccine and coverage achieved during measles supplemental
immunization activities (SIAs) conducted within the past three years. This indicator
also includes the proportion of suspected measles cases with unknown vaccination
status or who were unvaccinated.
o Total possible points = 40
 Surveillance quality: Evaluates the ability of a district to detect and confirm cases
rapidly and accurately. These indicators include the non-measles discarded rate; the
proportion of suspected measles cases with adequate investigation (investigation
within 48 hours of notification and inclusion of 10 core variables); the proportion of
cases with adequate specimen collection (within 28 days of rash onset); and the
proportion of cases for whom laboratory results were available in a timely manner.
o Total possible points = 20
 Program performance: Assesses specific aspects of routine immunization services,
including indicators for trends in MCV1 and MCV2 coverage, dropout rates from
MCV1 to MCV2 and from first dose of diphtheria, pertussis, and tetanus vaccine
(DPT1) to MCV1 based on administrative vaccination coverage data.
o Total possible points = 16
 Threat assessment: Accounts for factors that might influence the risk for measles
virus exposure and transmission in the population. The indicators include reported
measles cases among specific age groups, recent measles cases reported in a
bordering district, population density, and presence of vulnerable groups.
o Total possible points = 24

To ensure programmatic utility of the Risk Assessment Tool, it is intended to be used

periodically by national program managers to monitor implementation of measles
elimination strategies within a country. The Risk Assessment Tool is not meant to be used
for predicting outbreaks, but rather for preventing them. Results from the Risk Assessment
Tool should not be used for planning measles SIA campaigns, but rather to strengthen a
country’s immunization and surveillance programs.

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The required data inputs include readily-available and routinely collected data from the
immunization and surveillance programs. Results are shown in table and map formats,
with districts color-coded by risk category. In addition, district risk scores can be displayed
by indicator category, facilitating better understanding of programmatic weaknesses that
are driving the overall risk score.

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2. Data Inventory
Data Inventory
(District level and for 3 years
prior to assessment year)
Year
EPI unit
1. Administrative MCV1 coverage
data for each district
2. Administrative MCV2 coverage
data for each district (if introduced)
3. Administrative DPT1 (or Penta1
if used) coverage data for each
district
4. Measles Supplementary
Immunization Activity (SIA)
campaign data (if any SIA was
conducted within the past 3 years)
- Coverage data (for each district)
- Target age group(s) for SIA
- Year in which SIA was conducted
5. Total population data (for each
district)
6. Geographic area, in km2 (for each
district)
7. Shape file of country
(at the district level)
8. Completed ‘Vulnerable Groups by
District’ spreadsheet
Surveillance unit
1. Measles case-based surveillance
data
Data prior to
assessment year
Year Year
1 2 3 Notes
If coverage survey estimates are available
at the district level, were conducted within
the past 3 years, and include birth cohorts
√ √ √
of the past 3 years, these can be used in
place of administrative coverage for MCV1
and MCV2.
If coverage survey estimates are available
at the district level, were conducted within
the past 3 years, and include birth cohorts
√ √ √
of the past 3 years, these can be used in
place of administrative coverage for MCV1
and MCV2.
√
If no nationwide SIA was conducted in the
past 3 years but an outbreak response
immunization (ORI) campaign was
performed for an entire district, you can
√ report ORI coverage in place of SIA
coverage. If post-SIA coverage survey
estimates are available at the district level,
these can replace administrative coverage
for an SIA.
√ √ √
Geographic area of districts may be
√ included in the shape file, or may be listed
in a separate file.
If districts changed over years 1-3, you
√ √ √ should have shape files for each year. If no
changes, use the shape file for year 3.
√
Include the surveillance data dictionary
√ √ √ (or explanation of coding for each
variable)
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3. Indicators

3.1. Population Immunity

Population immunity indicators assess susceptibility to measles using
administrative vaccination coverage data for MCV1 and MCV2 and coverage achieved
during measles SIAs conducted within the past three years. It also includes the proportion
of suspected measles cases with unknown vaccination status or who were unvaccinated.

Table 3.1. Population Immunity Indicators: Cut-offs and Risk Points.

Risk Risk Risk Risk Risk
Population Immunity (40%) Cut-off Cut-off Cut-off Cut-off Cut-off
point point point point point
MCV1 coverage ≥95% 0 90-94% 2 85-89% 4 80-84% 6 <80% 8
Percentage of neighboring
<50% 0 50-74% 2 ≥75% 4
districts with <80% MCV1
MCV2 coverage ≥95% 0 90-94% 2 85-89% 4 80-84% 6 <80% 8
Yes,
Yes, Yes, 90- Yes, 85-
Measles SIA conducted within <85%
≥95% 0 94% 2 89% 4 6 No SIA 8
the past three years coverage
coverage coverage coverage
/no data
Target age group of measles
Wide age Narrow
SIA conducted within the past 0 2
group age group
three years
Years since last measles SIA <1 year 0 2 years 2 ≥3 years 4
Percent of suspected measles
cases with unvaccinated or <20% 0 >20% 6
unknown vaccination status

1. Administrative MCV1 coverage

Data source: Administrative coverage data from EPI
Calculate the average administrative coverage of the first dose of measles-
containing vaccine (MCV1) in each district from the past three years to assign risk
point. If coverage survey estimates are available at the district level (conducted within
the past three years and include birth cohorts of recent three years), these can be
used in place of administrative coverage. Risk points are assigned based on the
average administrative coverage in each district from the past three years.

Year 1 MCV1 coverage+Year 2 MCV1 coverage+Year 3 MCV1 coverage

MCV1 coverage = 3

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2. Percent of neighboring districts with MCV1 <80%
Data source: Administrative data from EPI
Assess representativeness of immunity gap in surrounding area of a district
using the average MCV1 coverage from the previous three years. If coverage survey
estimates are available at the district level (conducted within the past three years and
includes birth cohorts of recent three years), these can replace administrative
coverage. The percent of districts with MCV1 <80% is calculated for each district by
dividing the number of neighboring districts with <80% MCV1 by the total number of
neighboring districts (i.e., the number of neighboring districts that share a border).
(Note: In the current version of the Risk Assessment Tool, this indicator only accounts
for bordering districts within the same country. If data allow, bordering districts in
bordering countries should also be included in this indicator.)

Number of neighboring districts with<80% MCV1

Percent of districts with MCV1 <80% = Total number of neighboring districts

3. Administrative MCV2 coverage

Data source: Administrative data from EPI
Calculate the average administrative coverage of the second dose of measles-
containing vaccine (MCV2) in each district from the past three years to assign risk
point. If MCV2 was introduced in the past three years, then use only the years with
reported coverage. If MCV2 has not been introduced, then give the maximum score.

Year 1 MCV2 coverage+Year 2 MCV2 coverage+Year 3 MCV2 coverage

MCV2 coverage = 3

4. Subnational coverage of measles SIA

Data source: Administrative data from EPI
Vaccination coverage associated with a measles supplemental immunization
activity (SIA) campaign conducted within the past three years. Districts with >95%
for both MCV1 and MCV2 receive 0 risk points. If no nationwide SIA was conducted in
the past three years but an outbreak response immunization (ORI) campaign was
performed for an entire district, report ORI coverage to assign risk point. If post-SIA
coverage survey estimates are available at district level, these can replace
administrative coverage. If measles SIAs are not part of the national strategy, assign 0
risk points (i.e. countries in post-elimination period or high-income countries).

5. Measles SIA target age group

Data source: Administrative data from EPI
Target age group of measles SIA conducted within the past three years. Narrow
age group is defined as <5 birth cohorts (9m-59m or less); wide age group is defined
as >5 birth cohorts (greater than 9m-59m). Districts with >95% for both MCV1 and 2

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receive 0 risk points. If measles SIAs are not part of national strategy, assign 0 risk
points (i.e., countries in post-elimination period or high-income countries). If measles
SIAs are part of national strategy but were not conducted within the past three years,
assign 2 risk points.

6. Years since last measles SIA

Data source: Administrative data from EPI
The number of years since the last measles SIA was conducted, using the
evaluation year as the index year (e.g., if the evaluation year is 2015, and the last SIA
was conducted in 2011, the value for this indicator would be 4 years). If measles SIAs
are not part of the national strategy, assign 0 risk points (i.e. countries in post-
elimination period or high-income countries). Districts with >95% for both MCV1 and
MCV2 receive 0 risk points. If the SIA spanned two years, use the most recent year for
this calculation.

7. Percent of suspected measles cases who were unvaccinated

Data source: Measles case-based surveillance
Among suspected measles cases reported through case-based surveillance
during the past three years, the percentage who were unvaccinated for measles or
who had unknown measles vaccination status. Limit the calculation to only among
suspected cases who were age-eligible for MCV1 (i.e., if MCV1 is administered at age 9
months, only suspected cases age >9 months should be included).

Percent of suspected measles cases who were unvaccinated =

Suspected measles cases who were unvaccinated+Suspected measles cases with unknown vaccination status
Total number of suspected measles cases who were age−eligible for MCV1

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3.2. Surveillance Quality
Surveillance quality indicators evaluate the ability of districts to detect and confirm
cases rapidly and accurately. These indicators include the non-measles discarded rate; the
proportion of suspected measles cases with adequate investigation (investigation within 48
hours of notification and inclusion of 10 core variables); the proportion of cases with
adequate specimen collection (within 28 days of rash onset); and the proportion of cases
for whom laboratory results were available in a timely manner.

Table 3.2. Surveillance Quality Indicators: Cut-offs and Risk Points.

Surveillance Quality (20%) Cut-off Risk point Cut-off Risk point Cut-off Risk point
Non-measles discarded rate ≥2 0 <2 4 <1 8
Percent of suspected measles cases with adequate
≥80% 0 <80% 4
investigation
Percent of suspected measles cases with adequate
≥80% 0 <80% 4
specimen collection (within 28 days of rash onset)
Percent of suspected measles cases with timely availability
≥80% 0 <80% 4
of laboratory results

1. Non-measles discarded rate

Data source: Measles case-based surveillance
Calculate yearly discarded rate for the previous year. Yearly discarded rate
equals the number of discarded cases divided by the population, per 100,000. For
countries that have introduced rubella vaccine, use non-measles, non-rubella
discarded rate. If measles case-based surveillance has not been introduced, then give
the maximum score. For districts with populations less than 100,000, expected
discarded rate should be modified: For districts with a population of between 50,000
and 99,999, the district should receive 0 risk points if they had at least 1 discarded
case, and otherwise should receive 8 risk points. For districts with a population of
less than 50,000, the district should receive 0 risk points regardless of whether they
had any discarded cases or not.

Number of discarded cases

Yearly discarded rate (per 100,000) = x 100,000
Population

2. Percent with adequate investigation

Data source: Measles case-based surveillance
Assign risk points based on the previous year. An adequate investigation is
defined as a case investigated within 48 hours of notification AND includes all 10 core
variables listed below. To calculate the time between case notification and
investigation, use variables for the date the health facility was notified and either the
date the investigation form was sent to the district or the date of specimen collection.
If no investigations were conducted in a district, then give the maximum score.

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 Possible variable names in case-
Core variables
based surveillance dataset
1. Case identification IDNumber
2. Date of birth/age AgeInyears
3. Sex Sex
4. Place of residence DistrictofResidence
5. Vaccination status or date of last vaccination NumberOfVaccinedoses
6. Date of rash onset DateOfonset
7. Date of notification DateHealthfacilitynotified
8. Date of investigation DateSentFormtodistrict
9. Date of blood sample collection DateSpecimencollected
10. Place of infection or travel history ReportingHealthfacility

Number with adequate investigation

Percent with adequate case investigation = Total number of suspected measles cases

3. Percent with adequate specimen collection (within 28 days of rash onset)

Data source: Measles case-based surveillance
Assign risk points based on the previous year. Among suspected measles cases,
the percent who had an adequate blood specimen collected within 28 days of rash
onset. To calculate the time between rash onset and specimen collection, use variables
for the date of rash onset and the date that a specimen was collected.
Epidemiologically-linked cases should be excluded from this calculation. If no
specimens were collected, then give maximum score.

Percent with adequate specimen collection =

Number with specimen collected within 28 days
Suspected measles cases − epidemiologically−linked cases

4. Percent with timely availability of laboratory results

Data source: Measles case-based surveillance
Assign risk points based on the previous year. Availability of laboratory report
of results within 10 days of the date of specimen collection. To calculate the time
between specimen collection and laboratory report of results, use variables for the
date that a specimen was collected and the date that the district received the
laboratory results. If no specimens were received, then give maximum score. (Note: In
some regions timely availability may be defined as a different time period, but this is
the global standard and should be used generally.)

Percent with timely availability of laboratory results =

Number with laboratory results available within 10 days
Suspected measles cases with specimens collected

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3.3. Program Delivery Performance
Program delivery performance indicators assess specific aspects of routine
immunization services, including indicators for trends in MCV1 and MCV2 coverage,
dropout rates from MCV1 to MCV2 and from first dose of diphtheria, pertussis, and tetanus
vaccine (DPT1) to MCV1 based on administrative vaccination coverage data

Table 3.3. Program Delivery Performance Indicators: Cut-offs and Risk Points.
Program Delivery Performance (16%) Cut-off Risk point Cut-off Risk point Cut-off Risk point
Increasing ≤10% >10%
Trends in MCV1 coverage 0 2 4
or same decline decline
Increasing ≤10% >10%
Trends in MCV2 coverage 0 2 4
or same decline decline
MCV1-MCV2 dropout rate ≤10% 0 >10% 4
DPT1-MCV1 dropout rate ≤10% 0 >10% 4

1. MCV1 coverage trend

Data source: Administrative data from EPI
Trend in administrative MCV1 vaccination coverage from the past three years
by fitting a straight line. Risk points are assigned based on the slope of the trend line
in the past three years.

2. MCV2 coverage trend

Data source: Administrative data from EPI
Trend in administrative MCV2 vaccination coverage from the past three years
by fitting a straight line. If MCV2 was introduced in the past three years, then use only
the years with reported coverage. If MCV2 has not been introduced, then give the
maximum score. Risk points are assigned based on the slope of the trend line in the
past three years.

3. MCV1-MCV2 dropout rate

Data source: Administrative data from the EPI
The dropout rate for MCV vaccine is computed based on coverage of MCV1 and
MCV2 in the previous year and presented as a percentage. If MCV2 has not been
introduced, then give the maximum score.

MCV1 coverage − MCV2 coverage

MCV1-MCV2 dropout rate = MCV1 coverage

4. DPT1/Penta1-MCV1 dropout rate

Data source: Administrative data from the EPI
The dropout rate for DPT/Penta-MCV1 is computed based on coverage of
DPT1 (or Penta1) and MCV1 in the previous year and presented as a percentage.

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 DPT1 coverage – MCV1 coverage
DPT1-MCV1 dropout rate = DPT1 coverage
4.4. Threat Assessment
Threat assessment indicators account for factors that might influence the risk for
measles virus exposure and transmission in the population. The indicators include
reported measles cases among specific age groups, recent measles cases reported in a
bordering district, population density, and presence of vulnerable groups

Table 3.4. Threat Assessment Indicators: Cut-offs and Risk Points.

Risk Risk Risk Risk Risk
Threat Assessment (24%) Cut-off Cut-off Cut-off Cut-off Cut-off
point point point point point
≥1 measles case reported in past
No 0 Yes 4
year among those aged <5 years
≥1 measles case reported in past
year among those aged 5-14 No 0 Yes 3
years
≥1 measles case reported in past
No 0 Yes 3
year among those aged ≥15 years
101-
Population density (per km2) 0-50 0 51-100 1 2 301-1000 3 >1000 4
300
≥1 measles case reported in a
No 0 Yes 2
bordering district in past year
up to
Presence of vulnerable One risk point for each max
No vulnerable groups 0
population groups vulnerable group of 8
(1-8)

1. Evidence of recent measles cases among children <5 years of age

Data source: Measles case-based surveillance
One or more confirmed or measles compatible case reported in a district
within the past calendar year among children <5 years of age. Include lab-confirmed,
epidemiologically-linked, and clinically compatible cases. Exclude discarded cases.

2. Evidence of recent measles cases among children 5-15 years of age

Data source: Measles case-based surveillance
One or more confirmed or measles compatible case reported in a district
within the past calendar year among children 5-15 years of age. Include lab-
confirmed, epidemiologically-linked, and clinically compatible cases. Exclude
discarded cases.

3. Evidence of recent measles cases among those >15 years of age

Data source: Measles case-based surveillance
One or more confirmed or measles compatible case reported in a district
within the past calendar year among those >15 years of age. Include lab-confirmed,

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epidemiologically-linked, and clinically compatible cases. Exclude discarded cases.

4. Population density
Data source: Administrative data from National Statistics Office or local knowledge
Population density can be calculated from recent population data divided by
geographic area (km2) for each district.

5. Bordering area with measles case in the past 12 months

Data source: Measles case-based surveillance
One or more confirmed or measles compatible cases reported in a bordering
district within the past calendar year. Include lab-confirmed, epidemiologically-
linked, and clinically compatible cases. Exclude discarded cases. This indicator is
representative of the threat of importation. All land borders should be considered at
risk; for island borders, refer to local knowledge whether there is frequent population
movement with neighboring district. (Note: In the current version of the Risk
Assessment Tool, this indicator only accounts for bordering districts within the same
country; if data allow, bordering districts in bordering countries should also be
included in this indicator.)

6. Presence of vulnerable population groups

Data source: Local knowledge; can be completed at the national or district level by EPI
manager(s) or others with local knowledge
Assign one risk point for each of the following vulnerable population groups
present in a district. Presence of chronically unreached due to:
1) Presence of migrant population, internally displaced population, slums, or tribal
communities
2) Resistant to vaccination (i.e., religious, cultural issues, etc.)
3) Security and safety concerns
4) Frequented by calamities/disasters
5) Poor access to health services due to terrain/transportation issues
6) Lack of local political support
7) Presence of high-traffic transportation hubs/major roads or bordering large urban
areas (within and across countries)
8) Presence of areas with mass gatherings (i.e., trade/commerce, fairs, markets,
sporting events, high density of tourists)

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4. Risk Scoring
To establish cut-off criteria for risk categories, a distribution was constructed consisting of
all possible combinations of scores from each indicator. Risk categories are defined by the
50th, 75th, and 90th percentiles of this distribution. Using fixed cut-off points based on the
distribution allows for standardization of risk assignments and comparisons across
countries and regions, as well as within a country over time.

Risk Categories Total risk points

Low risk ≤ 47
Medium risk 48-54
High risk 55-60
Very high risk ≥ 61

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