Pan American Health Organization · Revised edition, 2022
Revised procedures for national sustainability committees and regional monitoring of measles/rubella elimination in PAHO Member States
- Issuer
- Pan American Health Organization
- Edition
- Revised edition, 2022
- Audience
- National immunization programmes, surveillance directorates, national reference laboratories, National Sustainability Committees, public health officials
- Evidence
- Expert consensus by Measles and Rubella Elimination Regional Monitoring and Re-Verification Commission, endorsed by PAHO Technical Advisory Group on Vaccine-preventable Diseases
- Reviewed
- 18 Oct 2026 · GMJ
What this guideline says
GMJ summary
This revised edition establishes the framework for monitoring sustained measles and rubella elimination and re-verifying countries that have lost elimination status in the Americas. After the Region was declared measles-free in 2016, endemic transmission was reestablished in Venezuela (Bolivarian Republic of) in 2018 and Brazil in 2019, with 41,007 confirmed cases reported across 18 countries during 2017–2019. The framework requires countries that lost elimination status to document absence of virus transmission for at least 12 months before re-verification.
The framework establishes six core components for country reporting: epidemiology; quality of surveillance (≥2 suspected cases per 100,000 population annually); molecular epidemiology and laboratory surveillance; analysis of vaccinated population cohorts (≥95% coverage with two MMR doses); sustainability measures; and correlation of all evidence. A new Measles and Rubella Elimination Regional Monitoring and Re-Verification Commission (MRE-RVC) replaces the former International Expert Committee, supported by National Sustainability Committees in each country that must meet at least annually and submit approved reports through Ministers of Health.
Countries must maintain sensitive surveillance meeting multiple indicators (≥80% thresholds for adequate investigation, specimen collection within 30 days, laboratory testing in proficient facilities, and ≥80% of outbreaks with genotype information). The framework includes specific criteria to verify outbreak interruption: absence of confirmed cases for 12 weeks, contact tracing for all cases in the last 21 days of an outbreak, active case-finding in silent municipalities, and rapid vaccination monitoring in high-risk areas. CRS surveillance requires ≥1 suspected case per 10,000 live births annually.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Countries require ≥2 suspected measles/rubella cases notified per 100,000 population annually at national and subnational levels to demonstrate sensitive surveillance
- At least 80% of suspected cases must have adequate investigation (8 of 11 data points completed), blood specimen collected within 30 days of rash onset, and testing in proficient laboratories
- Vaccination coverage ≥95% with two doses of MMR vaccine must be maintained homogeneously at national, subnational and municipal levels
- Outbreak interruption requires 12 weeks without confirmed cases following rash onset of last case, in the presence of high-quality surveillance
- At least 80% of outbreaks must have genotype information available; ≥80% of confirmed cases require respiratory specimen collected within 7–14 days or urine within 7–10 days of rash onset
- CRS surveillance requires ≥1 suspected case per 10,000 live births annually; ≥80% of confirmed CRS cases must have genotype information and monitoring of virus excretion with ≥2 negative results after 3 months of age
- Countries that reestablished endemic transmission must document absence of same genotype/lineage circulation for ≥12 months across the territory before applying for re-verification
- National Sustainability Committees must meet at least twice annually, comprise 5–7 independent multidisciplinary experts free of conflicts of interest, and submit annual country reports approved by the Minister of Health
Measles and rubella surveillance indicators
Table extracted from the guideline
| Criteria | Indicator | Minimum threshold |
|---|---|---|
| Reporting Rate | Annual rate of suspected measles and rubella cases at the national level | ≥2 per 100,000 population |
| Reporting Rate | Annual rate of suspected measles and rubella cases at the subnational level | ≥2 per 100,000 population (or ≥1 case if population <100,000) |
| Suspected Cases Adequate Investigation | Percentage suspected cases with household visit within 48 hours following reporting | ≥80% |
| Suspected Cases Adequate Investigation | Percentage suspected cases with 8 of 11 data points completed | ≥80% |
| Confirmed Cases | Percentage confirmed cases with contact tracing for 30 days | ≥80% |
| Laboratory Confirmation (adequate specimens) | Percentage suspected cases with blood specimen collected within 30 days of rash onset | ≥80% |
| Laboratory Confirmation (adequate specimens) | Percentage suspected cases with respiratory specimen collected within 7–14 days of rash onset | ≥80% |
| Laboratory Confirmation (adequate testing) | Percentage suspected cases with adequate blood specimens tested in a proficient laboratory | ≥80% |
| Viral Detection | Percentage outbreaks with genotype information available | ≥80% |
Source: Pan American Health Organization, Regional Framework for the Monitoring and Re-Verification of Measles, Rubella and Congenital Rubella Syndrome Elimination in the Americas. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- New requirement that endemic countries must document absence of measles or rubella virus transmission for more than one year (increased from previous criteria) to meet re-verification criteria
- Establishment of new Measles and Rubella Elimination Regional Monitoring and Re-Verification Commission (MRE-RVC) replacing the former International Expert Committee (IEC)
- Addition of Terms of Reference for National Sustainability Committees (NSC) as Annex 5, specifying composition, functions, and operational requirements
- Updated template for country reports now covering two-year periods annually (after initial 2016–2020 report) rather than longer intervals
- Inclusion of COVID-19 pandemic impact considerations in surveillance analysis and requirement to document activities to close immunity and surveillance gaps
- Enhanced molecular epidemiology requirements with specific guidance on virologic surveillance of transmission chains and visualization of genotype/lineage data
- Addition of guiding questions (Annex 6) to support correlation of evidence across the six main components
- Requirement for National Sustainability Committees to meet at least twice annually (increased from annual meetings)
From the guideline
Verbatim
“Endemic countries will now have to document absence of measles or rubella virus transmission for more than one year to meet re-verification criteria.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Chair of the Public Health Institute of Georgia, I find this framework particularly relevant given Georgia's sustained measles elimination since 2011 but persistent challenges with suboptimal coverage in some mountainous regions and among mobile populations. The requirement for National Sustainability Committees to meet at least twice annually—comprising independent experts with no conflicts of interest—provides a robust accountability mechanism that Georgia should adopt or strengthen. The emphasis on homogeneous municipal-level coverage ≥95% and active case-finding in epidemiologically silent areas addresses a critical vulnerability: our surveillance system may miss cases in remote Adjara, Samtskhe-Javakheti or among internally displaced populations. The most actionable recommendation for Georgian clinicians is the systematic approach to outbreak verification requiring genotyping of all outbreaks and contact tracing within 48 hours, which demands strengthened laboratory capacity at the Lugar Center and formalized rapid response teams at regional level. One realistic implementation caveat: achieving ≥80% respiratory or urine specimen collection within 7–14 days of rash onset will require significant investment in cold chain logistics and training for rural primary care physicians who currently focus on blood specimens alone.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 18 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia, which introduced measles-rubella vaccine in 2004 and achieved 95% coverage by 2009, has maintained elimination status but faces risks from suboptimal coverage in some regions and cross-border population movement with neighbouring countries experiencing outbreaks. This framework is directly applicable: Georgia would need to ensure its national surveillance system maintains the ≥2 suspected cases per 100,000 threshold, strengthen laboratory capacity for genotyping to document any imported cases, and establish or reactivate a National Sustainability Committee with independent multidisciplinary experts to annually review evidence of sustained elimination. The emphasis on homogeneous municipal-level coverage ≥95%, active case-finding in silent areas, and rapid response preparedness (particularly prevention of nosocomial transmission) are critical for Georgia given its universal health coverage system established in 2013 and ongoing health system strengthening. Regional coordination with Armenia, Azerbaijan and Turkey would be essential given shared borders and population mobility patterns.
Questions this guideline answers
Quick answers
What surveillance indicators must a country meet to demonstrate sustained measles/rubella elimination?
Countries must notify ≥2 suspected measles/rubella cases per 100,000 population annually at national and subnational levels. At least 80% of suspected cases must have adequate investigation (8 of 11 data points), blood specimen collected within 30 days of rash onset, and testing in a proficient laboratory. At least 80% of outbreaks must have genotype information, and 80% of confirmed cases should have contact tracing for 30 days.
How long must a country demonstrate absence of virus transmission before re-verification of elimination?
Countries that reestablished endemic transmission must document absence of measles or rubella virus circulation for at least 12 months following the date of rash onset of the last confirmed case. This must be demonstrated through epidemiological surveillance showing no confirmed cases for 12 weeks, molecular epidemiology confirming cessation of the same genotype/lineage, and evidence of increased population immunity and vaccination of susceptible individuals.
What are the criteria to verify interruption of a measles outbreak?
Outbreak interruption requires: absence of confirmed measles cases for 12 weeks following rash onset of the last case; final classification of all suspected cases in affected municipalities; contact tracing documented for all confirmed cases in the last 21 days; negative weekly reporting in ≥80% of reporting units at subnational level; active case-finding in silent municipalities and areas within 12 weeks of the last case; homogeneous surveillance indicators ≥80% nationally and subnationally; Rapid Vaccination Monitoring in high-risk municipalities; and active laboratory searches.
What is the composition and function of National Sustainability Committees?
National Sustainability Committees comprise 5–7 independent multidisciplinary experts (epidemiology, virology, pediatrics/medicine, public health, vaccinology) appointed by the Minister of Health for 3–4 year terms, free of conflicts of interest with no direct affiliation to the National Immunization Program, Surveillance Directorate or National Reference Laboratory. They must meet at least twice annually to review and approve country reports on sustainability, ensure all Regional Framework components are met, advocate for resources, and implement recommendations from the Regional Commission. Reports must be officially submitted through PAHO Representatives.
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- ASF PHC — Standard 4 — Acute & Same-Day Care · Primary Health Clinic
- ASF PHC — Standard 7 — Governance & Staffing · Primary Health Clinic
- ASF Hospital — Standard 5 — Safety & Emergency Preparedness
- ASF Hospital — Standard 11 — Critical Care
- ASF Medical Transport — Standard 6 — Emergency Response During Transport
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- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- Revised edition, 2022
- Replaces
- Plan of Action for the Documentation and Verification of Measles, Rubella, and Congenital Rubella Syndrome Elimination in the Region of the Americas, 2011
- Status
- Current
- Published
- 2022-01-01
- Languages
- English
- Scope
- Regional framework for 35 PAHO Member States in the Americas
- Audience
- National immunization programmes, surveillance directorates, national reference laboratories, National Sustainability Committees, public health officials
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-75-32669-5 (PDF)
- Evidence
- Expert consensus by Measles and Rubella Elimination Regional Monitoring and Re-Verification Commission, endorsed by PAHO Technical Advisory Group on Vaccine-preventable Diseases
- Record history
- Created 18 Oct 2026 · updated 18 Oct 2026 · next check Apr 2027
Pan American Health Organization. Regional Framework for the Monitoring and Re-Verification of Measles, Rubella and Congenital Rubella Syndrome Elimination in the Americas. Revised edition. Washington, DC: PAHO; 2022.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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