Measles surveillance sepio mtg 18 20 may 2011 (ab) v1

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by Dr Anindya Bose

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  • Corneal scarring Associated with vitamin A defiency Historically the most common cause of blindness in children in Africa, India Encephalitis: Older child more typically - High mortality rate Survivors high rate of disability as here Pneumonia & diarrhea: Pneumonia usually bacterial. Most common cause of post-measles death Note also the skin peeling, a characteristic sign of a healing measles rash
  • 1. Vaccine does not contain a preservative Needs diluent from manufacturer – not saline, not sterile water, not tap water, etc.
  • This is the result of strengthening routine EPI in Bangladesh. As per the data of 2010 CES 52 of 64 district which is more than 80% had already reached > than 80% measles coverage. And the presented figures are valid coverage of children who vaccinated with the first dose before they reach one year of age.
  • Imm data: Biases = Recall bias (mostly from verbal recall in absence of imm cards) + Observer Bias as local ANM is often the data collector RJ = Failure to vaccinate; TN = Failure of 1 dose of vaccine.

Transcript

  • 1. Measles: Disease, epidemiology and surveillance: Data for Action Dr A S Bose, WHO Workshop on Immunization Programme, GoI Hotel Royal Plaza, New Delhi 19 May 2011
  • 2. Overview
    • Measles virus, disease, and transmission
    • Measles vaccine
    • Control strategies and evidence of impact
    • India surveillance data
    • Linking surveillance data to control activities
  • 3. Source: Global measles elimination. Moss WJ & Griffn DE. Nature Dec 2006, Vol 4: 900-908
  • 4. Source: Global measles elimination. Moss WJ & Griffn DE. Nature Dec 2006, Vol 4: 900-908
  • 5. Clinical course of measles Incubation period ( 7–18 days before rash) 18 days before rash Exposure happened the earliest 18 days before rash 4 days before rash Is the probable start of infectiousness Prodrome (about 4 days) -18 -17 -16 -15 -14 -13 -12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 4 days after rash Is the probable end of infectiousness Rash (about 4–8 days) RASH The case can be identified here
  • 6. Measles disease
    • One of the most infectious agents known
    • Classic manifestations:
      • Fever / Maculopapular rash / The 3C: Cough, Coryza (runny nose), Conjunctivitis (red eyes)
    • Humans are the only reservoir
    • Multiplies in the respiratory tract
    • Airborne transmission via respiratory secretions or aerosols
    • Complications: mostly in 2nd and 3rd weeks
    • Case Fatality Ratio (CFR):
      • 0.1 – 10 % (highest in children <2 yrs)
      • May reach up to 30% in humanitarian emergencies
    • Lack of timely medical care for complications and malnutrition leads to high CFR
  • 7. Measles complications Corneal scarring causing blindness Vitamin A deficiency (Common) Encephalitis Older children, adults ≈ 0.1% of cases Chronic disability Pneumonia & Diarrhea (Common) Diarrhea common in developing countries Pneumonia ~ 5-10% of cases, usually bacterial desquamation
  • 8. Measles vaccine
    • Composition: live virus - freeze dried powder (no preservative)
    • Requires reconstitution (diluent from manufacturer)
    • Efficacy depends on age
      • At 9 months of age 85%
      • At 12 months of age 95%
    • Vaccine provides long-lasting immunity (likely lifelong)
  • 9. Coverage and immunity
    • Vaccination coverage does not equal population immunity!
    • 95% population immunity not achievable with only 1 dose (routine) even at very high vaccination coverage
    • Accumulation of susceptible persons occurs over time
    • High risk of outbreak when number of susceptibles in <5 population (primary vaccine failure + all unvaccinated) ≥ birth cohort
    Second opportunity for vaccination against measles needed to achieve & sustain high population immunity
  • 10. Overview
    • Measles virus, disease, and transmission
    • Measles vaccine
    • Control strategies and evidence of impact
    • India surveillance data
    • Linking surveillance data to control activities
  • 11. Measles control strategies *GIVS target > 90% nationally, > 80% in every district Case Management Surveillance 2 nd dose coverage (routine delivery or SIAs) 1 st dose coverage Vitamin A Supportive Rx Aggregate or case-based > 90%* > 90%* Mortality Reduction Vitamin A Supportive Rx Case-based > 95% > 95% Elimination
  • 12. Evidence of impact: Bangladesh When strategies are properly implemented
  • 13. Measles vaccination valid coverage by 12 months of age, 2005 and 2010 Source: CES 2005 and 2010 2005 2010 81% (52/64) districts achieved ≥80% coverage in 2010
  • 14. Impact of Measles Immunization Campaigns: Marked Reduction of Cases from Lab Confirmed Outbreaks Bangladesh, 2004-2010 (May) Source: Monthly case-based data up to May 2010 Accelerated Measles Surveillance
  • 15. Lack of impact and resurgence of disease: WHO African Region When strategies are not implemented properly or not in a sustained manner
  • 16. No. of reported measles cases and coverage with 1 st dose of measles containing vaccine (MCV1) in infants WHO African Region 2000-2010* *Source: Measles outbreaks and progress towards meeting measles pre-elimination goals: WHO African Region 2009-2010. [Editorial note] Weekly Epidemiological Record. No. 14 1 st April 2011
  • 17. Measles outbreak in WHO African region 2009-2010: Reasons*
    • “… Suboptimal coverage of routine immunization and SIAs led to accumulation of susceptible individuals…”
    • “… Outbreak cases occurring among older children and young adults suggest long standing gaps in vaccination activities
      • Reports of SIA administrative coverage >100% suggest that reported coverage figures may have been inaccurate and inflated …”
    *Source: Measles outbreaks and progress towards meeting measles pre-elimination goals: WHO African Region 2009-2010. [Editorial note] Weekly Epidemiological Record. No. 14 1 st April 2011
  • 18. Overview
    • Measles virus, disease, and transmission
    • Measles vaccine
    • Control strategies and evidence of impact
    • India surveillance data
    • Linking surveillance data to control activities
  • 19. India: Lab supported measles outbreak surveillance Linkage with program decisions
  • 20. NPSP assisted Measles Surveillance 2006 (Surveillance initiated) 2007 (Surveillance initiated) 2010 (Surveillance initiated) 2009 (Surveillance initiated) Reporting of Clinical Measles cases linked with AFP weekly reporting in these states; Weekly aggregate data should be mutually shared with IDSP One state level lab strengthened in each state. Lab testing for measles and rubella IgM. 2011 2011 2011 2011 (Surveillance planned)
  • 21. Scale-up of laboratory supported measles outbreak surveillance 2006 2007 2010 2009 2011 (Planned) Reporting of Clinical Measles cases linked with AFP weekly reporting in these states; Weekly aggregate data should be mutually shared with IDSP One state level lab strengthened in each state. Lab testing for measles and rubella IgM.
  • 22. Serologically confirmed # measles, rubella and mixed outbreaks, India (Andhra Pradesh, Gujarat, Karnataka, Kerala, Madhya Pradesh, Rajasthan, Tamil Nadu and West Bengal) 216 outbreaks 68 56 41 196 16 4 2009 2010* 165 outbreaks # Outbreak confirmation for Measles: 2009 ≥ 1 cases IgM positive for measles, Similarly for Rubella Outbreak confirmation for Measles: 2010 ≥ 2 cases IgM positive for measles, Similarly for Rubella * data as on 15 th Apr, 2011 Widespread measles virus transmission Low coverage Districts in high coverage states Mixed outbreaks confirmed Rubella outbreaks confirmed Measles outbreaks confirmed
  • 23. 2008 Total cases- 2118 2009 Total cases- 464 Measles cases by age, 2008-2011, Gujarat Cases from serologically confirmed measles and mixed outbreaks % % 2010 Total cases- 973 % 2011* Total cases- 710 % * data as on 15 th Apr, 2011
  • 24. 2010* Total cases- 1453 Measles cases by age, 2008-2011, Madhya Pradesh % 2008 No reporting in 2008 Cases from serologically confirmed measles & mixed outbreaks No reporting in 2009 * data as on 15 th Apr, 2011 2009 2011* Total cases- 197 %
  • 25. 2008 2011* Total cases- 349 Measles cases by age, 2008-2011, Rajasthan % 2009 No reporting in 2008 2010 Total cases- 1141 % Cases from serologically confirmed measles & mixed outbreaks * data as on 15 th Apr, 2011 Total cases- 293 %
  • 26. N=213 Andhra Pradesh N=301 Gujarat N=363 Tamil Nadu N=686 Madhya Pradesh West Bengal N=705 Karnataka Measles cases (1-4 years) by vaccination status, 2010* N=517 Rajasthan N=680 Cases from serologically confirmed measles & mixed outbreaks N=227 Kerala * data as on 15 th Apr, 2011 Vaccinated Not Vaccinated Unknown
  • 27. N=195 Andhra Pradesh N=457 Gujarat N=311 Tamil Nadu N=531 Madhya Pradesh N=649 West Bengal N=464 Karnataka Measles cases (5-9 years) by vaccination status, 2010* Cases from serologically confirmed measles outbreaks N=442 Rajasthan N=243 Kerala * data as on 15 th Apr, 2011 Vaccinated Not Vaccinated Unknown
  • 28. Bihar: Measles outbreak surveillance
    • Processes for systematic surveillance initiated last month
    • Data presented here based on outbreaks investigated ad-hoc per state Govt. request
      • All outbreaks investigated with laboratory testing
    • 2008-2011: 5 fever & rash outbreaks investigated; all outbreaks lab confirmed to be measles
      • 527 cases, 16 deaths
      • Overall Case-fatality ratio: 3%
    • Observed CFR should be interpreted in context of ad-hoc investigations
  • 29. Total cases- 202 Outbreaks- 2 Total cases- 136 Outbreak- 1 Total cases- 189 Outbreaks- 2 2008 2010 2011 Measles cases by age, Bihar, 2008-2011* Cases from serologically confirmed measles outbreaks % % * data as on 15 th May, 2011 %
  • 30. Serologically confirmed measles outbreaks – Bihar, 2008-2011* Vaccination status of measles cases by age N=22 N=219 N=235 N=37 N=14 1-4 years 5-9 years 10-14 years >=15 years < 1 year * data as on 15 th May, 2011 Vaccinated Not Vaccinated Unknown
  • 31. Case Fatality Ratios in lab confirmed measles outbreaks: catch-up campaign states
  • 32. Overview
    • Measles virus, disease, and transmission
    • Measles vaccine
    • Control strategies and evidence of impact
    • India surveillance data
    • Linking surveillance data to control activities
  • 33. Measles outbreak surveillance: data informs program decisions
    • Measles surveillance
      • Among 6 EPI diseases, most outbreak prone and easily recognizable
      • Most cases are clinically manifest
      • Last EPI antigen in infant immunization schedule
      • Measles outbreaks flag areas with suboptimal infant immunization coverage (measles and other antigens)
    • Summary of evidence from measles surveillance
      • Lab evidence of measles transmission in all states
      • Mortality burden higher in catch-up campaign states (high burden states)
      • Immunization status: largely a problem of “failure to vaccinate” in catch-up campaign states
      • <10 year old children bear 90% of disease burden in catch-up campaign states
  • 34. Summary
    • Highly infectious outbreak prone disease
    • Highly effective (2 doses) live attenuated vaccine available
    • Control and elimination strategies work if implemented properly in a sustained manner
    • India: 2 dose strategies needed for all states
      • State specific delivery strategies
    • Tasks ahead:
      • Implement 2-dose strategies (RI and SIA) fully and properly
      • expand lab supported surveillance in all catch-up campaign states with full state ownership
    Thank You
  • 35. Back-up slides
  • 36. Serologically confirmed # measles, rubella and mixed outbreaks, India (Andhra Pradesh, Gujarat, Karnataka, Kerala, Madhya Pradesh, Rajasthan, Tamil Nadu and West Bengal) 68 outbreaks 65 2 1 2011* # Outbreak confirmation for Measles: 2011 ≥ 2 cases IgM positive for measles, Similarly for Rubella * data as on 15 th Apr, 2011 Mixed outbreaks confirmed Rubella outbreaks confirmed Measles outbreaks confirmed
  • 37. Measles case fatality ratio, Bihar, 2008-2011* * data as on 15 th May, 2011 3.04 527 16 Total 3.96 202 8 2011 0.00 189 0 2010 5.88 136 8 2008 Fatality rate Total Measles cases Total Measles Deaths Year