In July 2020, World Health Organization officially announced that Maldives was verified for the elimination of rubella based on the recommendation of WHO South-East Asia Regional Verification Commission for Measles and Rubella. This feat was achieved several years ahead of the 2023 target and was the result of decades of dedication from the Ministry of Health, generations of health workers, communities, as well as the technical guidance and support of WHO and the contribution of United Nations Children’s Fund (UNICEF). Since the introduction of the measles vaccine in 1981, WHO has advocated for the primary health care approach, supported strategic interventions, and provided technical support for the national vaccination programmes, achieving >95% coverage of the MR and MMR vaccine in the past decade.
Elimination of disease as a national pride: building capacity
Elimination of Rubella was high on the agenda as it is one the key targets of the regional flagship programme of the WHO South-East Asia Region. WHO has been working in close collaboration with the National Verification Committee and Maldives Technical Advisory Group on Immunization, guiding the national programme. Leading up to 2020, WHO Maldives supported the Health Protection Agency in developing a plan towards attaining and validating rubella elimination. The WCO coordinated input from experts and facilitated the assessment of the two essential criteria and five lines of evidence needed for the validation process. Based on the initial findings, WCO incorporated appropriate activities into the WHO work plan and built capacity in Maldives to work towards elimination. Specifically, WHO Maldives helped introduce the second dose of rubella-containing vaccine in routine immunizations in 2017 and in launching the measles and rubella catch-up campaigns in 2017 and 2020, which were inclusive of the migrant population. Furthermore, the rubella case definition was recently expanded in the existing case-based surveillance system to avoid overlooking any potential cases. Since the case-based surveillance system had been in operation since 2010, WCO provided extensive technical support and training for doctors, nurses, and all relevant healthcare professionals in adopting this new case definition. This resulted in increased identification of suspected cases, which allowed WCO to then promptly test and diagnose. WCO also brought in experts to improve proficiency of laboratories, working with the Global and Regional Measles and Rubella Laboratory Network to accurately diagnose rubella. These efforts contributed to a robust and effective surveillance system spanning the many islands and consequently strengthened the health systems, the health workforce, and preparedness to identify and respond to outbreaks.
COVID-19 adaptations & scenario-based approaches
There have been significant disruptions to routine immunization services and also a decrease in demand for services due to the pandemic around the world [1]. Thankfully, WHO Maldives’ advice on quick and responsive adaptation of services has successfully helped the government maintain good levels of routine immunization throughout 2020. As Maldives is a nation composed of geographically dispersed islands, WHO proposed a scenario-based approach. With careful consideration for each island’s context and COVID-19 situation, the government made decisions to maintain operations without interruptions and acted swiftly to adapt services while balancing the demands of the pandemic. Early on, WHO developed and distributed a guideline for vaccinations during the COVID-19 pandemic in two languages for local usage. Further, in anticipating the decrease in demand and services, WHO also implemented the “measles and rubella intensification activities” at local health centres for communities (as opposed to holding mass immunization campaigns, which would draw large crowds). As the healthcare staff turnover rate is high in Maldives, WHO supported the recruitment of international and local experts, to support reliable and thorough investigation of suspected cases of rubella.
WCO’s support for the national programme in the rigorous detection, data collection, and documentation ultimately helped produce the Ministry of Health’s submission to the National Verification Committee for the certification of rubella elimination in 2020. The elimination of rubella and CRS is surely a success story to be celebrated during the challenging times of the COVID-19 pandemic and speaks more broadly, to WHO’s delivery of its international commitment and reward in strengthening primary health care systems.
Glossary
MR – measles, rubella
MMR – measles, mumps, and rubella
[1]. Special feature: immunization and COVID-19 [Internet]. World Health Organization. 2020 [cited 10 February 2021]. Available from: https://covid.comesa.int/immunization/monitoring_surveillance/immunization-and-covid-190/en/
Photo caption: Routine immunization service in Maldives continues adopting “new normal” during the COVID-19 pandemic.
Photo credit: WHO
