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Measles

Dr. Rizwan S A, M.D.,

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Outline
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Terminology
History
Burden
The disease
Epidemiology
The vaccine
Measles control in India
Surveillance
Measles and MGD 4
Feasibility of eradication
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Outline
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•
•
•
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Terminology
History
Burden
The disease
Epidemiology
The vaccine
Measles control in India
Surveillance
Measles and MGD 4
Feasibility of eradication
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Terminology – 1/2
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Measles control:
– reduction of measles morbidity and mortality in accordance with targets;
continued intervention measures are required to maintain the reduction.
Measles elimination:
– the situation in a large geographical area in which endemic transmission of
measles has stopped and sustained transmission does not occur following the
occurrence of an imported case; continued intervention measures are
required.
Measles eradication:
– interruption of measles transmission worldwide as a result of deliberate
efforts; intervention methods may no longer be needed. Eradication
represents the sum of successful elimination efforts in all countries.
Outbreak:
– the number of cases observed is greater than the number normally expected
in a given geographical area during the same period of time. The definition of
an “outbreak” will vary according to the country and its phase of control.
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Terminology – 2/2
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High Risk:
– floating children, street children, working children, children in prison, slums and
brothel, migratory types, children living in tea estates, rice mills, brick kilns, construction
sites, hard to reach areas etc.
Supplementary immunization activity (SIA):
– Mass campaigns targeting all children in a defined age group, with the objective of
reaching a high proportion of susceptible. Includes catch up and follow up campaigns
Measles Catch-up campaign:
– A one-time event targeting multiple cohorts in which susceptible children have
accumulated.
– All children in the target age group receive a supplementary dose regardless of previous
vaccination history or illness.
Measles Follow-up campaign:
– A periodic event (every 3-5 years, according to the accumulation of susceptible)
targeting children born after catch-up campaign to reduce susceptibles
– The target age group - all children aged over nine months who were born after the
previous mass immunization.
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Outline
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Terminology
History
Burden
The disease
Epidemiology
The vaccine
Measles control in India
Surveillance
Measles and MGD 4
Feasibility of eradication
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History
• References to measles – as early as 7th century
• Described by the Persian physician Rhazes in the 10th century
as “more dreaded than smallpox.”

• 1846 - Peter Panum described incubation period of measles
and lifelong immunity after recovery
• 1954 - Enders and Peebles isolated the virus in human and
monkey kidney tissue culture
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Outline
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Terminology
History
Burden
The disease
Epidemiology
The vaccine
Measles control in India
Surveillance
Measles and MGD 4
Feasibility of eradication
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Burden – global…1
• 2011 global figures
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344,276 reported cases
139,300 estimated deaths (2010)
84% estimated MCV coverage
65% of countries reached >=90% MCV coverage

• By 2008 global mortality has reduced from 733,000 in 2000 to
164,000 in 2008 (78% reduction)

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Burden – global…2
• Estimated no. of deaths globally: 2000 to 2010

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Burden – SEAR…1

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Burden – SEAR…2

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Burden – India…1
• Data reported by NHP, CBHI
– 2008: total cases - 44258, deaths – 191
– 2009: total cases - 56188, deaths – 48
– 2010: total cases – 29808, deaths – 32

• Only country in SEAR that does not report
measles cases to WHO

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Burden – India…2
• In 2005, an estimated 92,000 deaths occurred in India from
measles among children aged <5 years (1).
• In 2008, 77% of global measles mortality occurred in SEAR,
the majority of which occurred in India (2,3).
• These figures highlight the importance of India in attaining
regional and global measles mortality reduction targets

1. Kumar R, Awasthi S, Bassani DG, et al. Causes of neonatal and child mortality in India: a nationally representative mortality survey. Lancet 2010;376:1853--60.
2. World Health Organization. Global reductions in measles mortality 2000--2008 and the risk of measles resurgence. Wkly Epidemiol Rec 2009;84:509--16.
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3. CDC. Global measles mortality, 2000--2008. MMWR 2009;58:1321--6.
Burden – India…3

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Burden – India…4
• As evident from the figure above, before the launch of
Measles vaccination under the UIP in 1985, over 100,000
cases of Measles occurred each year in the country.
• Prior to 1985 there were outbreaks at an interval of about 3
years, after the introduction of Measles vaccination the
number of cases decreased and also the interval between
outbreaks also increased (about 5 years).

WHO/UNICEF Joint Annual Measles Report. 2009
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Burden – India…5
• Laboratory-confirmed
measles and rubella
outbreaks in states
conducting measles
outbreak surveillance —
India, 2010

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Outline
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Terminology
History
Burden
The disease
Epidemiology
The vaccine
Measles control in India
Surveillance
Measles and MGD 4
Feasibility of eradication
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The disease
• Measles is an acute highly contagious viral disease caused
by measles virus
• Measles virus
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Paramyxovirus, genus Morbillivirus
Important surface antigen – Hemagglutinin
Only one antigenic type
Rapidly inactivated by heat and light
It has a short survival time (less than 2 hours) in the air or on objects
and surfaces

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Pathogenesis
• Respiratory transmission of virus
• Replication of nasopharynx and regional lymph nodes
• Primary viremia 2 to 3 days after exposure
• Secondary viremia 5 to 7 days after exposure with spread to
tissues

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Clinical features – 1/2
• Incubation period – 10 to 12 days
• Prodome – stepwise increase in fever to 103 F or higher,
cough, coryza, conjunctivitis, koplik spots
• Rash
– 2 to 4 days after prodome,
– 14 days after exposure,
– persists 5 to 6 days,
– begins on face and head,
– maculopapular, becomes confluent
– fades in order of appearance
Koplik spots - a rash - enanthem present on mucous membranes, is considered to be pathognomonic for measles. It occurs 1–2
days before the rash to 1–2 days after the rash, and appears as punctate blue-white spots on the bright red background of the
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buccal mucosa.)
Clinical features – 2/2

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Complications - 1/2
• 30% of reported measles cases have one or
more complications
• More in < 5 years and > 20 years
• MC – diarrhea

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Complications – 2/2
• During pregnancy - premature labor, spontaneous abortion, and LBW
• Birth defects (with no definable pattern of malformation) have been
reported rarely
• Atypical measles - persons who received inactivated (“killed”) measles
vaccine (KMV) and subsequently exposed to wild-type measles virus,
characterized by fever, pneumonia, pleural effusions, and edema
• Modified measles (mild illness) - patients who received immune
globulin (IG) as postexposure prophylaxis and in young infants who
have some residual maternal antibody
• Hemorrhagic measles - high fever (105°–106°F), seizures, delirium,
respiratory distress, and hemorrhage into skin and mucous
membranes
• Measles in an immunocompromised person (e.g. AIDS) may be severe
with a prolonged course
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Laboratory diagnosis
• Isolation of virus from clinical specimen – urine, nasopharynx,
blood, throat swab
• Significant rise in IgG titre by EIA or HA

• Positive IgM antibody for measles

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Basic principles of case management
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Anticipate complications
Encourage breast feeding
Provide nutritional support
Administer vitamin A (2 doses as per age)
Fever management
Diarrhoea management
Treat eyes to prevent blindness
Use antibiotics if indicated
Admit severely ill children
Monitor growth
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Outline
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Terminology
History
Burden
The disease
Epidemiology
The vaccine
Measles control in India
Surveillance
Measles and MGD 4
Feasibility of eradication
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Epidemiology
• Occurs throughout the world
• Interruption of indigenous transmission of measles achieved
in the USA and some parts of Western Hemisphere
• Host – man, no animal reservoir, no asymptomatic carrier
state
• Agent – Measles virus (MV)
• Transmission – respiratory airborne
• Temporal pattern – late winter and spring
• Communicability – 4 days before to 4 days after rash onset,
highly communicable, > 90% secondary attack rates
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Epidemiology in pre-vaccination era – 1/2
• Infection was nearly universal during childhood, > 90% of
persons were immune by age 15 years
• In large unimmunized populations, incidence varies cyclically.
• An increase in no. of susceptibles or in frequency of contact
between infectious individuals and susceptibles leads to an
increase in measles incidence.
• As incidence rises, no. of susceptible persons decreases; this
reduces the chances of contact between infectious and
susceptible person and measles incidence begins to fall.
• As incidence falls, susceptibles accumulate until a threshold is
passed, at which time measles transmission increases again.
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Epidemiology in pre-vaccination era – 2/2
• The length of the inter-epidemic interval depends on the rate
of accumulation of susceptibles, which is in turn dependent
on population density, birth rate and migration patterns.
• In urban areas of Africa, epidemics occurred every 1-2 years
in the pre-immunization era.
• In urban areas of the USA, epidemics occurred every 2-5
years prior to immunization
• In developing countries - Important foci of transmission have
been health centres, the homes of neighbours or relatives in
other villages
• In developed countries, schools have been important places
of contact
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Effect of immunization on the epidemiology - 1
• Programmes that immunize a portion of the birth cohort each
year slow down the rate of entry of new susceptibles and
decrease incidence
• This leaves some children susceptible to infection till an older
age, leading to a shift in the age distribution of measles
towards older children and a lengthening of the interepidemic interval.
• This period of low incidence following widespread
immunisation is called ‘honeymoon period’

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Effect of immunization on the epidemiology - 2
• As the cohorts grow older while the disease incidence is low,
most persons acquire immunity from exposure to the vaccine
rather than to the disease.
• If coverage is less than 100%, and the vaccine is less than
100% effective, the incidence will rise after a long lowincidence period, though remaining lower than the preimmunization level with longer IE interval
• A dramatic short-term reduction in measles incidence after
mass immunization may be followed by the recurrence of
measles epidemics, at ever-increasing intervals.

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Effect of immunization on the epidemiology - 3
• In a highly immunized population, a large proportion of cases
occur among immunized persons, since there are so few
unimmunized persons.
– For example, if 98% of the population is immunized with a vaccine that
is 95% effective, 71% of cases are predicted to occur among
vaccinated persons

• In large urban areas, the pool of children who have lost
maternal antibodies but have not yet reached the minimum
age for immunization contributes to sustaining measles
transmission even at high coverage levels.
– Vaccines which can be applied at 6 months of age will assist in measles
control in areas where measles before the age of 9 months is a
significant cause of death
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Effect of immunization on the epidemiology - 4
• Apparent negative effects of immunization programme
– Outbreaks occurring after raised coverage may lead to a loss of
confidence in immunization programme among health workers, the
public and political leaders.

– In countries with poorly developed surveillance prior to the
immunization programme the reported measles cases may even
increase as the programmes get stronger, because of increased
completeness of reporting.

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Effect of immunization on the epidemiology - 5
• Although measles out-breaks have begun to occur in older
children in some countries with high coverage, this is an
expected consequence of an immunization programme whose
target age group has been children under 2 years
• Another expected result of high coverage levels is an increase
in the proportion (but not the rate) of cases among previously
immunized children
• The occurrence of either of these does not necessarily
indicate programme failure.
• But still EPI has reduced measles incidence and mortality rates

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Experience from USA & Africa
• In response to the resurgence of measles, the USA has launched an
initiative to increase age-appropriate immunization coverage,
targeted to inner-city areas, and has recommended a routine
second dose of measles vaccine at school age, to protect the 2-5%
of persons who did not respond to initial dose of vaccine

• However, in some large cities in Africa, measles in children under 9
months old remains a major problem despite higher coverage rates
and has led to renewed interest in lowering the age for routine
measles immunization.

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Epidemiology of measles in India – early years of
vaccination
• The age of peak measles incidence in India was 1-2 years.
• Generally, occurs at a younger age in urban areas where
transmission is continuous as compared to rural areas where
measles is intermittent
• Endemic measles primarily occurs during the spring with incidence
starting to increase from January till April with peak in March.
• However Epidemics have occurred any time during the year
• Reported CFR from 1-3% while fatality rates among hospitalized
children as expected is much higher 15-20%
• One of the factors contributing to mortality is the reluctance of the
village people to seek treatment for complications because of
strong traditional beliefs.
• Vaccine efficacy studies – range of 80% to 100%
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Herd immunity in measles
• Immunization programmes aim to interrupt measles
transmission by inducing herd immunity
• The high transmissibility of measles makes herd immunity
difficult to achieve.
• Hope-Simpson estimated that 75.6% of household exposures
of susceptibles lead to measles transmission, compared to
61% for varicella and only 31.1% for mumps
• It has been estimated that around 95% immunization
coverage with a vaccine which is 100% effective must be
achieved to eliminate measles from a stable population.

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Outline
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Terminology
History
Burden
The disease
Epidemiology
The vaccine
Measles control in India
Surveillance
Measles and MGD 4
Feasibility of eradication
40
Vaccine
In the USA
• 1963 – killed and live attenuated (Edmonston B strain) vaccine
licensed
• 1965 – live attenuated (Schwarz strain)
• 1967 – killed vaccine withdrawn
• 1968 – live attenuated s (Edmonston-Enders strain)
• 1971 – combined MMR vaccine licensed
• 2005 – combined MMRV vaccine licensed

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Measles vaccine in India
• Edmonston-Zagreb strain
• Grown on human diploid cells or purified chick embryo cells.
• Each dose contains at least 1000 infective units and has no preservative.
Freeze-dried in single dose or multi dose vials with distilled water as
diluent.
• Stored frozen or at 2 to 8°C (shelf life 2 years).
• Reconstituted vaccine
– destroyed by light, heat labile, susceptible to contamination as it does not
have any preservative
– protected from light, kept at 2 to 8° C and used within 4-6 hours of
reconstitution

• Dose - 0.5 ml S.C/IM preferably over the upper arm/anterolateral thigh

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Immunisation responses
• Antibodies develop in 95% of children vaccinated at 12 months of age and
98% of children vaccinated at 15 months
• Sero-conversion rates are similar for single-antigen measles
vaccine, MMR, and MMRV
• Approximately 2%–5% of children who receive only one dose of MMR
vaccine fail to respond to it (i.e., primary vaccine failure)
• Most persons who fail to respond to the first dose will respond to a
second dose.
• Serologic and epidemiologic evidence indicate that vaccine-induced
immunity appears to be long-term and probably lifelong
• Schedule in the USA
– First dose of MMR at 12 to 15 months
– Second dose at 4 to 6 years (school entry) or any time after 4 weeks of
first dose
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Post-exposure prophylaxis
• Live measles vaccine provides permanent protection and may
prevent disease if given within 72 hours of exposure
• Immune globulin (IG) may prevent or modify disease and
provide temporary protection if given within 6 days of
exposure
• IG may be especially indicated for susceptible household
contacts of measles patients, esp. contacts younger than 1
year of age

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CI to immunisation
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Allergy to prior dose
Pregnancy
Immunosuppression
Moderate or severe acute illness
Personal or family history of seizures of any aetiology
Patients who are severely immuno-compromised for any
reason should not be given MMR vaccine
• HIV – MMR can be given for asymptomatic and mildly
symptomatic HIV infection, not for severe immunosupression

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AEFI
• Mild pain and tenderness may occur at the site of
injection
• Fever of at least 39.4 C occurs in 5% of recipients 7–
12 days following measles vaccination, and a
transient rash occurs in approximately 2% of
recipients
• Thrombocytopenia, allergic reactions

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Vaccine cost effectiveness
• Separate studies in Africa and South-East Asia found that adding
measles vaccine to a child health intervention package was highly cost
effective.
• Where routine immunization coverage is low, SIAs or mobile outreach
services cost <US$ 100 per additional case averted when compared
with administering a single routine dose alone.

• Dayan GH et al. Cost-effectiveness of three different vaccination strategies against measles in Zambian children. Vaccine, 2004, 22:475–
484.
• Van Damme W, Van Lerberghe W. Strengthening health services to control epidemics: empirical evidence from Guinea on its costeffectiveness. Tropical Medicine and International Health, 2004, 9:281–291.
• Vijayaraghavan M et al. Economic evaluation of measles catch-up and follow-up campaigns in Afghanistan in 2002 and 2003. Disasters,
2006, 30:256–269.
• Commission on Macroeconomics and Health. Macroeconomics and health: investing in health for economic development. Report of the
Commission on Macroeconomics and Health. Geneva, World Health Organization, 2001.
• Edejer TT et al. Cost effectiveness analysis of strategies for child health in developing countries. British Medical Journal, 2005, 331:1177

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WHO position paper on vaccine – 1/2
• Recommended for all susceptible children and adults without
contraindications
• All children with 2 doses of measles vaccine should be the standard
for all national immunization programmes
• Reaching and maintaining high immunization coverage remains the
cornerstone
• Optimal age for MCV1
– In countries with ongoing transmission - 9 months
– In countries with low transmission - 12 months

• MCV2 may be added to the routine immunization in countries
with ≥80% coverage of MCV1 at the national level for 3
consecutive years
• Countries that do not meet this criterion should prioritize
improving MCV1 coverage and conducting high quality follow-up
SIAs
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WHO position paper on vaccine – 2/2
• Optimal timing of routine delivery of MCV2
– Countries with MCV1 delivered at age 9 months, should administer
routine MCV2 at age 15–18 months
– In countries with low measles transmission where MCV1 is
administered at 12 months, the optimal age for delivering routine
MCV2 is based on programmatic considerations (either 15-18 months
or school entry)

• Criteria for stopping follow-up SIAs
– >90–95% immunization coverage at the national level for both
MCV1 and routine MCV2 as determined for a period of at least 3
consecutive years.
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Outline
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Terminology
History
Burden
The disease
Epidemiology
The vaccine
Measles control in India
Surveillance
Measles and MGD 4
Feasibility of eradication
51
Measles control in India

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Control achieved by SEAR
• The South-East Asia Region (SEAR) has a goal of 90% reduction
in measles mortality by 2010 in comparison to 2000 estimates
• Achieved by all countries in the region except India by 2008

• Including India, overall mortality reduction only reached 46%,
with routine coverage up to 75% (2008) from 61% (2000)

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Coverage with 1 dose of measles-containing vaccine among
children aged 12–23 months, by district — India, 2007–2008*

• DLHS 3 reports a coverage of
69.6% for MCV1
• CES 2009 reported a coverage of
74.1% for MCV1

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Trends in MCV1 coverage in India

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Initial steps
• Little information is available about measles
epidemiology in India.
• Reliable surveillance data are missing and few outbreaks
are investigated.
• India is setting up surveillance for outbreak prevention
while continuing to address the challenges of measles
control.
• In 2005, a national strategic plan was formulated.

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Multi-year strategic plan India: 2005-10
• Addresses the issue of reducing the measles mortality by twothirds by 2010, compared to 2000.
• To achieve at least 90% coverage in 80% of the districts of the
country by 2009 and collection and use of good quality
epidemiological data from active surveillance and outbreak
investigation
• Challenges: Ensuring societal and political support, ensuring
adequate supplies of measles vaccine of assured quality
• As per the draft comprehensive Multi Year Strategic Plan (cMYP,
2010-17) for immunization aims to reduce by 90% mortality by
2013 as compared to 2000.
• Prior to 2010, India was the only country that had not introduced a
2nd dose
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Global Context: Worldwide measles vaccination
delivery strategies - 2010

MCV1 & MCV2, no SIAs (40 member states or 21%)

India national immunization
programmeintroduced
second dose of measles in 2010
Data source: WHO/IVB measles database as of 26 January 2010

MCV1, MCV2 & one-time catch-up (36 member states or 19%)
MCV1, MCV2 & regular SIAs (57 member states or 28%)
MCV1 & regular SIAs (59 member states or 31%)
Single dose (1 member state or 1%)

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Key Strategies for Measles Mortality Reduction
1. High coverage of measles 1st dose
2. Sensitive laboratory supported surveillance
3. Case management including vitamin A supplementation
4. 2nd opportunity for vaccination

There are 2 ways of providing 2nd opportunity they are
a. Routine 2nd dose of measles
b. Supplementary Immunization Activity (SIA) for measles

Source: Measles Mortality Reduction – India Strategic Plan 2005-10

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Monitoring
• Indicators to monitor the implementation of measles control strategies at
State and National levels
– Number of States with measles plan of action
– Annual number of reported measles cases and deaths nationally, by States
and districts
– Percentage of outbreaks investigated by States
– Percentage of known outbreaks confirmed serologically
– Measles immunization coverage
– State & District level
– Percentage of districts with routine measles coverage <50%, 50-79%, 80-90%,
90%+
– Coverage of SIAs- State & District level
– Percentage of districts with mass campaign coverage level <80%; 80-90% and
>=90%
– Completeness and timeliness of monthly surveillance reports
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Rationale for Measles Catch-up Campaign
• Analysis of measles outbreak data for the period 2006 to 2009, in
states with outbreak surveillance reveals that around 90% of the
measles cases were in the age group of <10 years
• As measles vaccination does not confer 100% protection and
seroconversion rate is only 85% when given at 9 months of age, a
substantial number of children remain unprotected even if they are
vaccinated
• Measles catch-up campaign is required to sustain high measles
vaccination coverage and also for providing a second opportunity
for the unprotected children
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Rationale for second dose
• 40% of India’s annual birth cohort of 26 million children remain
susceptible to measles
– Routine measles vaccination coverage - 70%
– Vaccine effectiveness(single dose,9 months) - 85%
– Real protection to measles = 60% (0.70 × 0.85=0.60)

• Immunological - immunize the primary vaccine failures (those children
who failed to respond to the first dose)
• Programmatic - to vaccinate those children who were missed by routine
services
• Most children who have failed to respond to the first dose of MCV respond
well to a second dose*
• Two doses of measles vaccine highly cost effective #

*World
#

Health Organization, Measles vaccines: WHO position paper. Wkly Epidemiological Rec. 2009; 84
World Health Organization, Measles vaccines: WHO position paper. Wkly Epidemiological Rec. 2009

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Recommendations from expert Indian
committees
• National Technical Advisory Group on Immunization (NTAGI)
recommended:
1. States with MCV1 coverage <80%: Second opportunity for
measles vaccine through measles catch-up campaigns in 9
months - 10 years age
2. States with MCV1 coverage >80%: MCV2 through routine
immunization at 16-24 months of age
• Ad hoc expert review committee reviewed above strategy in early
2010 and endorsed the NTAGI recommendation
• 21 states qualify for MCV2 through RI and 14 states qualify for large
scale catch-up campaigns
• Of these 21 states, 4 states/UTs (Delhi, Goa, Puducherry and Sikkim)
are already using second dose of measles in their RI (MMR)

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Introduction of MCV2
• Decision to introduce 2nd dose measles vaccination -the draft
comprehensive Multi Year Strategic Immunization Plan of the
Government of India (cMYP 2010-2017)
• May 2010 -GOI announced its decision to implement NTAGI
recommendation to introduce MCV2#

* Measles Catch Up Immunization Campaign- Guidelines for Planning and Implementation. June 2010 Ministry of Health and Family Welfare, Government of

India.
and Recommendations of National Technical Advisory Group on Immunization (NTAGI), 16th June 2008, Ministry of Health and Family Welfare,
Government of India.

#Minutes

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Age for second dose
• 90% of confirmed measles outbreak occur in states with low
MCV1 coverage (<80%) are among children less than 10 years
of age*
• Hence, measles catch-up campaigns target children 9 months
to 10 years of age in the 14 states

*Measles Catch Up Immunization Campaign- Guidelines for Planning and Implementation. June 2010 Ministry of Health
and Family Welfare, Government of India.
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State-specific delivery strategies
• 14 states with measles coverage< 80%
– (Arunanchal
Pradesh, Assam, Bihar, Chattisgarh, Gujarat, Haryana, Jhark
hand, M.P, Manipur, Meghalaya, Nagaland, Rajasthan, Trip
ura and U.P)
– will introduce MCV2 through catch-up vaccination
campaigns
• In the remaining 21 states with better performing routine
immunization systems (i.e.,>=80% routine measles coverage)
• Delhi, Goa,Puducherry and Sikkim- already use 2nd dose
measles vaccine in their RI program (as MMR)
• Phase 1 measles catch-up campaign commenced in November
2010
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MCV2 introduction:
State-specific delivery strategies

SIA: MCV1 <80%: 14 states
RI: MCV1 >80%: 21 states

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Measles SIA - India

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MCUP: Basic considerations
• All children in target age-group (9 mo-<10 years) to be
vaccinated
– Irrespective of previous doses of measles vaccine received
– Irrespective of prior history of measles disease
• In general, this age group constitutes around 18-25% of the
total population
– Target: ~135 million children
– Expected coverage: More than 90% (evaluated coverage)
• Massive public health undertaking with an injectable vaccine
• Both safety and high coverage are critical
• MOH&FW decided to take a phased approach
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MCUP: Basic operational strategy
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•

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All immunizations from static posts (no HTH immunization)
Regular routine immunization sessions will be conducted without
interruption
– Two regular routine immunization clinics per week
– Measles catch-up campaign in remaining four days
Average Campaign duration: 3 weeks = 12 working days
– 1st week: School based campaign (for 5-10 year children)
– 2nd & 3rd weeks: Community based campaign for non-school going
children or children missed during school week
Training
– Only trained persons (ANMs) will work as vaccinators
– All ASHA/ AWW will be trained for beneficiary listing and Interpersonal communication
– Doctors (including clinicians in pvt. sector) have been trained in
managing rare adverse events, if any
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MCUP: session sites and teams
• Types of session sites
– Session sites at Educational Institutes
– Outreach site (regular RI sites and additional sites in
village/urban mohalla)
– Mobile/Special team
– Facility based session site
• Team composition
– 1-2 Auxiliary Nurse Midwife (ANMs)
– ASHA (Accredited Social Health Activist)
– AWW (Anganwadi Worker)
– Volunteer
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Overview of Measles SIA
J A M M U & K A S H M IR

HI M A C H A L
PR AD ES H
P U NJ A B
C H A N D IG A R H

UT T A R A K HA N D

HA RY A N A
DE LH I

A R UN A C H A L P R .
S IK K IM

UT T A R P RA DE S H
RA J A S T H A N

ASSA M
NA G A L A N D

B IH A R
M E G HA LA Y A

M A N IP U R
J HA RK HA N D
G UJ A R A T

MAD H YA PR AD ESH

TR IP U R A
W EST B EN G AL

M IZ O R A M

Phase 1, 45 districts covered (~ 13 million)
Phase 2, 152 districts covered (~ 40 million)

C H H A T T IS G A R H

O RI S S A

D A M A N & D IU
D& N HA V E L I

Phase 3, 167 districts planned (~ 81 million)

M A H A R A S H TR A

A N DH R A P RA D E S H
P O N D IC H E R R Y

KAR N ATAKA

GOA

A & N IS L A N D S

LA K S H A D W E E P

TA M IL N A D U

KER AL A

Target population:
 ~ 135 million children 9
months – 10 years of age
 365 districts in 14 states
Phase 1 in 2010 -11; Phase 2 in 2011-12; Phase 3 in 2012-13 Starting Sep 12

73
Measles SIA phasing plan, India
Total number of
Districts

Districts covered in
Phase 1

Districts covered in
Phase 2

ARUNACHAL PR.

16

1

15

ASSAM

26

1

25

BIHAR

38

5

15

CHHATTISGARH

18

9

9

GUJARAT

32

5

5

HARYANA

21

5

16

JHARKHAND

24

5

19

MADHYA PRADESH

50

5

13

MANIPUR

9

1

8

MEGHALAYA

7

1

6

NAGALAND

11

1

10

RAJASTHAN

33

5

5

TRIPURA

4

1

3

UTTAR PRADESH

75

State

Number of Districts
for Phase 3

18

22

32

23

3

72

Total

364

45

152

167

Target Population

~134,000,000

13,845,686

40,167,580

~81,000,000

12,076,836
(87.2%)

36,102,564
(89.9%)

Coverage
(% Achieved)

74
Coverage achieved: Administrative and RCA
monitoring (MCUP Phase 1 & 2)

48,179,400 of 54,013,266 vaccinated (89.2%)

98 of 197 districts with >= 90% coverage

Number of
Children
monitored

2465

22438

287758

31462

49174

132343

140880

181299

160

3308

2175

41846

3280

27867

75
Campaign awareness & source of
information (in %)
100

94.9

90

83.7

80

•

70

•

60

•

50
40

Vast majority of those monitored were
aware of the campaign
Session sites with visible IEC material –
82.6%
Sites where social mobilization was being
done by house visits – 88.3%

30
16.4

20

7.7

10
0

Awarness for the
campaign

Health worker/
ASHA/AWW

N= 638,660 children monitored

Teachers

Family members/
Community

5.3
Newspaper/
Poster/ Banner

1.4
TV/Radio/Miking

76
Reasons for missing vaccination during Measles
catch-up campaigns-India (RCA)
Social mobilisation
Operational

52%
44%

4%

(N – 87,197)

Others
Social mobilisation includes
•Parents didn’t know of campaigns,
•Didn’t know about Place/Date,
•Didn't give Importance
•Fear of Injection & AEFI
Operational
• No vaccine/logistics
• No vaccinator
•Site too far, long queue
Others
•Family travelling, sick child,
•Gone to School etc

77
All State Governments have issued orders
to include Measles 2nd dose under RI in
campaign districts after 6 months
78
Measles SIA timeline (3rd phase)
MADHYA
PRADESH
Period of campaign

Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb -13

Mar -13
Apr-13

GUJARAT

RAJASTHAN

BIHAR

UTTAR
PRADESH

No. of Districts

12 (17 Sep) 22 (13 Sep) 9 (17 Sep)
7
8
5
8
6

18
22
16
11
23
79
Summary of measles 2nd dose
• Measles 2nd dose under RI at 16-24 months introduced in 21
States/UTs in 2010
• Measles SIA completed in 197 districts in 14 states with
coverage of 90% in two phases.
• In 9 states out of 14 completed measles SIA in all districts.
• 2nd dose of measles under RI started 6 month after measles SIA
• Remaining 167 districts in 5 states planned/ on going measles
SIA during 2012-13 with target of 81 million children (UP, MP,
BI, RAJ, GUJ)
• Case based surveillance, expansion of laboratory network,
• MEASLES 2ND DOSE WILL BE UNIVERASLIZED IN THE ENTIRE
COUNTRY BY 2014
80
Impact on measles transmission

[Data as on August 2012]

81
Measles cases and outbreaks in districts completed catch-up campaigns and
lab supported measles surveillance before and after start of MCUP
Pre-MCUP Surveillance data from MCUP
districts*
State

MCUP Phase &
(No. of districts
covered)

Reference
period (From)

2 (26)

Bihar

1 (5)

07-2011

NA

7

MCUP activity
completed by

MM-YYYY

Total number
of confirmed
measles
outbreaks

Total number
of confirmed
measles
cases

12-2010

12-2011

0

0

353

06-2012

08-2012

0

0

NA

1 (1)

Assam

Total number
of confirmed
measles
cases

NA

MM-YYYY

Total number
confirmed
measles
outbreaks

Post-MCUP Surveillance data from MCUP
districts #

NA

01-2011

01-2012

0

0

MM-YYYY

Reference
period (until)

2 (15)

06-2011

2

82

02-2012

08-2012

0

0

1 (5)

07-2010

14

546

07-2011

07-2012

0

0

2 (5)

03-2011

1

15

03-2012

08-2012

0

0

NA

NA

03-2011

03-2012

0

0

Gujarat

Jharkhand

1 (5)
2 (19)

7

238

03-2012

08-2012

0

0

1 (5)

07-2010

5

354

01-2011

01-2012

0

0

2 (13)

01-2011

8

492

01-2012

08-2012

0

0

1 (5)

12-2009

4

211

12-2010

12-2011

2

54

2 (5)

Madhya
Pradesh

07-2011

03-2011

3

60

03-2012

08-2012

0

0

1 ( 26)

23

1111

2

54

2 (83)

28

1240

0

0

Rajasthan

Grand
Total

82
Data as on 13/08/2012
Summary of MCV2 by SIA and RI
•

Of

14

states

implementing

measles

SIA,

6

states

(Assam, Bihar, Gujarat, Jharkhand, MP & Rajasthan) have lab supported measles

surveillance data to make before-after comparisons
– The ‘post’ window for phase-2 activity is <1 year (Range: 1-7 months) for all
states, Surveillance sensitivity is variable across states and should be taken
into account while interpreting results, Quality of MCUP activities have also
varied among states
•

Overall the MCUP strategy has been effective in reducing measles transmission

•

In measles 2nd dose states the size and frequency of measles outbreak reduced

•

Overall, in phase 1 & 2 districts
SIA

Outbreaks

Measles cases

Upto 1 yr before SIA

51

2351

Upto 1 yr after SIA

2

54

83
Outline
•
•
•
•
•
•
•
•
•
•

Terminology
History
Burden
The disease
Epidemiology
The vaccine
Measles control in India
Surveillance
Measles and MGD 4
Feasibility of eradication
84
NPSP assisted measles surveillance
Each state supported by a WHOaccredited lab

Year surveillance initiated
2006
2007
2009

2010
2011
85
Objectives of measles surveillance
•
•
•
•

Detect and investigate outbreaks
Identify high risk populations/areas
Strengthen vaccine coverage in these areas
Monitor reduction in mortality and morbidity

86
Components of surveillance
•
•
•
•

Reporting network – RU and informers
Data flow and analysis
Investigation and confirmation of outbreak
Consolidation of data at distt. and state level
to decide immunisation strategy

87
Reporting network
• All sites that are currently reporting AFP cases
– RUs: govt., and pvt., health facilities treating a
large no. of under 15 children – medical colleges,
distt. Hospitals, CHC, PHC
– Informers: smaller facilities and clinicians

• Additional sources
– IDSP

88
Reporting cases
• Who reports – all RUs and informers
• What – clinical measles cases
• When – RUs: weekly (mondays), informers: as
and when
• How - weekly reporting format (VPD-H002)
• To whom – DIO
• Nil report to be sent by RUs if no case is seen
89
Case definition
• Any person in whom clinician suspects measles

Or
• Any person with fever and maculopapular rash with
cough, coryza or conjunctivitis
• For epidemiological investigation, clinical measles
would be a case within last 3 months

90
Triggers for investigation outbreak
• >= 5 clinical cases in a block in a week
Or
• >= 1 death due to measles in a block in a week
Or
• >= 5 clinical cases in an area bordering several
blocks
91
Outbreak investigation
• Visit area
– To confirm whether looks like measles
– Presence of number of cases

• Collect detailed information from the community
• Collect blood from 5 cases with rash onest within 4 to 28 days
• Decide on level of response
– Strengthening of immunisation
– Proper case management

• Confirmation of outbreak by positive measles IgM in any 5
samples collected

92
Planning for outbreak investigation – 1/2
• Before
– Formation and orientation of Epidemic Response Team
(ERT)
– At distt. level
– Members : DM&HO, DIO, program officer (IDSP), Statistical
officer and surveillance medical officer (SMO)
– The MO may be included
– Role of ERT
• To plan and guide investigation
• Monitor progress in data collection, compile and analyse data and
give final report
• SMO is the technical guide
93
Planning for outbreak investigation – 2/2
• During
–
–
–
–
–
–
–
–
–
–
–
–

Identifying potential outbreak
Confirming outbreak and assigning a number
Mobilisation of ERT
Orientation and planning meeting at local level
Conducting measles case search
Collection and shipment of specimens to lab
Lab confirmation
Data analysis
Conversion of data into information for action
Report writing
Feedback
Initiating actions
94
Measles outbreak surveillance - 1
• Suspected Measles cases reported weekly from AFP
reporting units - built on strong AFP reporting network
• Data compiled at District to identify large outbreaks
• IDSP reports included
• Epidemic Response Team (ERT) and the EPI team in
• District decide on house-to-house search for cases
• Larger outbreaks investigated with serological testing
• Field investigation including case age and immunization
status
• Serologic confirmation (5 cases)
• Treatment (Vitamin-A, Antibiotics, ORS)
The National Polio Surveillance Project - India

95
Measles outbreak surveillance - 2
• Government functionaries involved at all stages
– ERT members: DIO/DSO/CMOH/others:
– Field Investigation: Local public health staff
– Sample collection and transport: Local facility lab staff

•

NPSP SMO: Many support multiple districts
– Trains District and Block Medical Officers
– Coordinates sample collection and shipment,
– Coordinates data compilation and flow

•

NPSP (Central and Regional level):
– Cross-check quality of data
– Monthly Bulletin - shared with GOI, states, partners
The National Polio Surveillance Project - India

96
Clinical measles cases, 2005-2011*, India
Andhra Pradesh, Assam, Bihar, Gujarat, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Rajasthan, Tamil Nadu
and West Bengal

N D J F M A M J J A S ON D

2005

J F M AM J J A S ON D J F M AM J J A S ON D

2006

2007

J F M AM J J A S ON D J F M AM J J A S ON D J F M AM J J A

2008

2009

2010

97
Serologically confirmed measles, rubella or mixed
(Andhra Pradesh, Assam, Bihar, Gujarat, Jharkhand, Karnataka, Kerala, Madhya Pradesh,

152 outbreaks
Measles outbreaks confirmed
Rubella outbreaks confirmed
Mixed outbreaks confirmed
98
Serologically confirmed measles outbreaks
Vaccination status of measles cases by age, 2010, India
4000

Total cases- 8,984

3500
3000
2500
2000
1500
1000
500
0

< 1 yr

1-4 yr

Vaccinated

5-9 yr
Not Vaccinated

10-14 yr

>= 15 yr

Unknown

*Cases from serologically confirmed measles outbreaks
99
Performance indicators for surveillance
•

•

Control stage for countries where measles is endemic
– Target: all indicators to be >80%
– % of districts reporting monthly;
– % of districts reporting within a month after the report period;
– % of reported cases containing core data (i.e. age, vaccination status).
– These indicators should be evaluated at least monthly. In countries where
weekly
– reporting is established, weekly evaluation of indicators may be preferred.
For countries at the low incidence or elimination stage, weekly basis.
– Performance indicators: Target: all indicators to be >80%
– % of sites reporting weekly
– % of cases notified within <48 hours of onset of rash
– % of cases investigated within <48 hours of notification
– % of cases with adequate specimen and laboratory results within 7 days
– % of confirmed cases with sources of infection identified
100
IDSP – measles

101
Definitions
• Clinical case description:
Any person with
– Fever and
– Maculo-popular rash lasting for more than 3 days
– Cough or coryza or conjunctivitisLaboratory criteria for diagnosis:
– At least a four fold increase in the anti body titre or
– Isolation of measles virus or
– Presence of measles specific IgM anti bodies

• Case classification
– Suspect case: Any case with fever & rash
– Probable case: Any suspect case who is diagnosed as measles by MO on
basis of clinical case description
– Confirmed case: A case that meets the clinical case definition and that is
Laboratory confirmed or linked epidemiological to a lab confirmed case
102
Response triggers
• Trigger Level-1 (Suspected limited outbreak, local response)
– A single case of measles in a tribal area
– More than 2 cases of fever with rash in a village/geographical area of
1000 population

• Trigger Level-2 (Epidemic, local & regional response)
– More than 4 cases of fever with rash in a geographical area of 1000
population
– Similar illness in more than 1 village reported in the same week

103
Outline
•
•
•
•
•
•
•
•
•
•

Terminology
History
Burden
The disease
Epidemiology
The vaccine
Measles control in India
Surveillance
Measles and MDG 4
Feasibility of eradication
104
Measles and MDG 4
• From 2000 to 2008, child mortality decreased by 1.6 million,
from an estimated 10.4 million to 8.8 million deaths;
• During the same period measles deaths declined by over 0.5
million (31% of total) suggesting that the decline in measles
has played a part in the overall decline in child mortality.
• Measles directly contributes to the reduction of under-five
child mortality and hence to the achievement of Millennium
Development Goal number 4.
• Improving measles vaccination coverage and reducing
measles-related deaths is a global imperative, particularly
as it relates to MDG 4
105
Overview of Key Statistics, 2000-2009
• Global routine measles vaccination coverage reached
83% in 2008, up from 71% in 2000.
• Measles vaccination prevented over 12.7 million
deaths globally over 2000-2008
• Between 2000 and 2008, global measles mortality
decreased by 78% from 733,000 deaths in 2000 to
164,000 in 2008.
–
–
–
–

Africa: 92%
Eastern Mediterranean: 93%
South-East Asia: 46% (80% if India is excluded)
Western Pacific: 92%

106
Outline
•
•
•
•
•
•
•
•
•
•

Terminology
History
Burden
The disease
Epidemiology
The vaccine
Measles control in India
Surveillance
Measles and MGD 4
Feasibility of eradication
107
Feasibility of global eradication

108
Global goals
• A 95% global mortality reduction goal by 2015
(compared with 2000) was adopted by the
WHO World Health Assembly in May 2010

109
Goal for measles elimination - SEAR
• At a regional measles consultation in New Delhi in August
2009
– all Member States agreed that regional measles elimination was
technically, biologically and programmatically feasible
– Eight countries (Bangladesh, Bhutan, Indonesia, Nepal, Thailand,
Myanmar, Maldives and Sri Lanka) agreed to set a goal for achieving
measles elimination by 2015
– Timor-Leste set a goal of 2020
– India did not set a target year for elimination goal

110
Feasibility
• Discussed since the introduction of vaccine
• 3 criteria – humans must be crucial for transmission
– sensitive and specific diagnostic tools
– effective intervention

• Many experts believe this is met by measles
• Eradicating measles by 2020 is projected to cost an additional
discounted $7.8 billion and avert a discounted 346 million
DALYs between 2010 and 2050*

*Ann Levin et al.Global Eradication of Measles: An Epidemiologic and Economic Evaluation. JID 2011:204 (Suppl 1)
111
Biological feasibility
•
•
•
•

No non-human reservoirs
Readily diagnosed after the onset of a rash
Virus has not mutated
Limitations
– Highly contagious, R o of 12 to 18 as compared to 5-7 for
smallpox
– Requires high level of population immunity to interrupt
transmission
– Contagious for several days prior to onset of rash
– Possibility of transmission from subclinical cases
– HIV epidemic – prolonged transmission: unlikely to hinder
112
Technical feasibility
• Vaccine is safe, effective
• Limitations
– Inactivated by light and heat
– Strict cold chain must be maintained
– injected SC or IM necessitating trained healthcare workers,
needles, syringes and the proper disposal of hazardous
waste
– Maternally antibodies and immunological immaturity
reduce the protective efficacy in early infancy

113
Logistical feasibility
• Two broad strategies
– In countries with sufficient infrastructure, the second dose through
routine immunization
– In others, mass-immunization campaigns - Catch-Up, Keep-Up, FollowUp and Mop-Up

• War and displaced popualtions
• Loss of public confidence - religious or philosophical grounds
• New tools - inexpensive, safe, heat-stable, immunogenic in
very young, single dose without the need to use a needle or
syringe

114
Prospects for global elimination
• Elimination of measles in large areas, such as the Americas,
suggests that global measles elimination is feasible
• Political and public support necessary – difficult in rich
countries
• Critics claim – diversion of resources from primary care and
vested foreign interests
• Serious discussion of measles eradication will probably take
place after polio eradication

115
WHO position on eradication
• WHO global technical consultation to assess the feasibility of
measles eradication, 2010
• The group concluded that measles can and should be
eradicated
• 
Milestones to eradication
– MCV1 Coverage of 90% at national level and 80% in all districts
– Incidence of <5 cases/million population
– Atleast 95% reduction compared to 2000

• Target dates for elimination region wise
– European 
and 
Eastern
 Mediterranean – 2015, WP – 2012, Afrcian –
2020, SEAR – 2020

• Eradication target to be set yet
116
Conclusion
• Controls efforts have reduced measles related
morbidity and mortality, esp. due to availability of an
effective vaccine
• Selected regions of the world like India need
concentrated efforts
• Measles eradication is a real possibility but will
require greater commitment from all stakeholders

117
Thank you

118

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Measles - Epidemiology and Control

  • 1. Measles Dr. Rizwan S A, M.D., 1
  • 2. Outline • • • • • • • • • • Terminology History Burden The disease Epidemiology The vaccine Measles control in India Surveillance Measles and MGD 4 Feasibility of eradication 2
  • 3. Outline • • • • • • • • • • Terminology History Burden The disease Epidemiology The vaccine Measles control in India Surveillance Measles and MGD 4 Feasibility of eradication 3
  • 4. Terminology – 1/2 • • • • Measles control: – reduction of measles morbidity and mortality in accordance with targets; continued intervention measures are required to maintain the reduction. Measles elimination: – the situation in a large geographical area in which endemic transmission of measles has stopped and sustained transmission does not occur following the occurrence of an imported case; continued intervention measures are required. Measles eradication: – interruption of measles transmission worldwide as a result of deliberate efforts; intervention methods may no longer be needed. Eradication represents the sum of successful elimination efforts in all countries. Outbreak: – the number of cases observed is greater than the number normally expected in a given geographical area during the same period of time. The definition of an “outbreak” will vary according to the country and its phase of control. 4
  • 5. Terminology – 2/2 • • • • High Risk: – floating children, street children, working children, children in prison, slums and brothel, migratory types, children living in tea estates, rice mills, brick kilns, construction sites, hard to reach areas etc. Supplementary immunization activity (SIA): – Mass campaigns targeting all children in a defined age group, with the objective of reaching a high proportion of susceptible. Includes catch up and follow up campaigns Measles Catch-up campaign: – A one-time event targeting multiple cohorts in which susceptible children have accumulated. – All children in the target age group receive a supplementary dose regardless of previous vaccination history or illness. Measles Follow-up campaign: – A periodic event (every 3-5 years, according to the accumulation of susceptible) targeting children born after catch-up campaign to reduce susceptibles – The target age group - all children aged over nine months who were born after the previous mass immunization. 5
  • 6. Outline • • • • • • • • • • Terminology History Burden The disease Epidemiology The vaccine Measles control in India Surveillance Measles and MGD 4 Feasibility of eradication 6
  • 7. History • References to measles – as early as 7th century • Described by the Persian physician Rhazes in the 10th century as “more dreaded than smallpox.” • 1846 - Peter Panum described incubation period of measles and lifelong immunity after recovery • 1954 - Enders and Peebles isolated the virus in human and monkey kidney tissue culture 7
  • 8. Outline • • • • • • • • • • Terminology History Burden The disease Epidemiology The vaccine Measles control in India Surveillance Measles and MGD 4 Feasibility of eradication 8
  • 9. Burden – global…1 • 2011 global figures – – – – 344,276 reported cases 139,300 estimated deaths (2010) 84% estimated MCV coverage 65% of countries reached >=90% MCV coverage • By 2008 global mortality has reduced from 733,000 in 2000 to 164,000 in 2008 (78% reduction) 9
  • 10. Burden – global…2 • Estimated no. of deaths globally: 2000 to 2010 10
  • 13. Burden – India…1 • Data reported by NHP, CBHI – 2008: total cases - 44258, deaths – 191 – 2009: total cases - 56188, deaths – 48 – 2010: total cases – 29808, deaths – 32 • Only country in SEAR that does not report measles cases to WHO 14
  • 14. Burden – India…2 • In 2005, an estimated 92,000 deaths occurred in India from measles among children aged <5 years (1). • In 2008, 77% of global measles mortality occurred in SEAR, the majority of which occurred in India (2,3). • These figures highlight the importance of India in attaining regional and global measles mortality reduction targets 1. Kumar R, Awasthi S, Bassani DG, et al. Causes of neonatal and child mortality in India: a nationally representative mortality survey. Lancet 2010;376:1853--60. 2. World Health Organization. Global reductions in measles mortality 2000--2008 and the risk of measles resurgence. Wkly Epidemiol Rec 2009;84:509--16. 15 3. CDC. Global measles mortality, 2000--2008. MMWR 2009;58:1321--6.
  • 16. Burden – India…4 • As evident from the figure above, before the launch of Measles vaccination under the UIP in 1985, over 100,000 cases of Measles occurred each year in the country. • Prior to 1985 there were outbreaks at an interval of about 3 years, after the introduction of Measles vaccination the number of cases decreased and also the interval between outbreaks also increased (about 5 years). WHO/UNICEF Joint Annual Measles Report. 2009 17
  • 17. Burden – India…5 • Laboratory-confirmed measles and rubella outbreaks in states conducting measles outbreak surveillance — India, 2010 18
  • 18. Outline • • • • • • • • • • Terminology History Burden The disease Epidemiology The vaccine Measles control in India Surveillance Measles and MGD 4 Feasibility of eradication 19
  • 19. The disease • Measles is an acute highly contagious viral disease caused by measles virus • Measles virus – – – – – Paramyxovirus, genus Morbillivirus Important surface antigen – Hemagglutinin Only one antigenic type Rapidly inactivated by heat and light It has a short survival time (less than 2 hours) in the air or on objects and surfaces 20
  • 20. Pathogenesis • Respiratory transmission of virus • Replication of nasopharynx and regional lymph nodes • Primary viremia 2 to 3 days after exposure • Secondary viremia 5 to 7 days after exposure with spread to tissues 21
  • 21. Clinical features – 1/2 • Incubation period – 10 to 12 days • Prodome – stepwise increase in fever to 103 F or higher, cough, coryza, conjunctivitis, koplik spots • Rash – 2 to 4 days after prodome, – 14 days after exposure, – persists 5 to 6 days, – begins on face and head, – maculopapular, becomes confluent – fades in order of appearance Koplik spots - a rash - enanthem present on mucous membranes, is considered to be pathognomonic for measles. It occurs 1–2 days before the rash to 1–2 days after the rash, and appears as punctate blue-white spots on the bright red background of the 22 buccal mucosa.)
  • 23. Complications - 1/2 • 30% of reported measles cases have one or more complications • More in < 5 years and > 20 years • MC – diarrhea 24
  • 24. Complications – 2/2 • During pregnancy - premature labor, spontaneous abortion, and LBW • Birth defects (with no definable pattern of malformation) have been reported rarely • Atypical measles - persons who received inactivated (“killed”) measles vaccine (KMV) and subsequently exposed to wild-type measles virus, characterized by fever, pneumonia, pleural effusions, and edema • Modified measles (mild illness) - patients who received immune globulin (IG) as postexposure prophylaxis and in young infants who have some residual maternal antibody • Hemorrhagic measles - high fever (105°–106°F), seizures, delirium, respiratory distress, and hemorrhage into skin and mucous membranes • Measles in an immunocompromised person (e.g. AIDS) may be severe with a prolonged course 25
  • 25. Laboratory diagnosis • Isolation of virus from clinical specimen – urine, nasopharynx, blood, throat swab • Significant rise in IgG titre by EIA or HA • Positive IgM antibody for measles 26
  • 26. Basic principles of case management • • • • • • • • • • Anticipate complications Encourage breast feeding Provide nutritional support Administer vitamin A (2 doses as per age) Fever management Diarrhoea management Treat eyes to prevent blindness Use antibiotics if indicated Admit severely ill children Monitor growth 27
  • 27. Outline • • • • • • • • • • Terminology History Burden The disease Epidemiology The vaccine Measles control in India Surveillance Measles and MGD 4 Feasibility of eradication 28
  • 28. Epidemiology • Occurs throughout the world • Interruption of indigenous transmission of measles achieved in the USA and some parts of Western Hemisphere • Host – man, no animal reservoir, no asymptomatic carrier state • Agent – Measles virus (MV) • Transmission – respiratory airborne • Temporal pattern – late winter and spring • Communicability – 4 days before to 4 days after rash onset, highly communicable, > 90% secondary attack rates 29
  • 29. Epidemiology in pre-vaccination era – 1/2 • Infection was nearly universal during childhood, > 90% of persons were immune by age 15 years • In large unimmunized populations, incidence varies cyclically. • An increase in no. of susceptibles or in frequency of contact between infectious individuals and susceptibles leads to an increase in measles incidence. • As incidence rises, no. of susceptible persons decreases; this reduces the chances of contact between infectious and susceptible person and measles incidence begins to fall. • As incidence falls, susceptibles accumulate until a threshold is passed, at which time measles transmission increases again. 30
  • 30. Epidemiology in pre-vaccination era – 2/2 • The length of the inter-epidemic interval depends on the rate of accumulation of susceptibles, which is in turn dependent on population density, birth rate and migration patterns. • In urban areas of Africa, epidemics occurred every 1-2 years in the pre-immunization era. • In urban areas of the USA, epidemics occurred every 2-5 years prior to immunization • In developing countries - Important foci of transmission have been health centres, the homes of neighbours or relatives in other villages • In developed countries, schools have been important places of contact 31
  • 31. Effect of immunization on the epidemiology - 1 • Programmes that immunize a portion of the birth cohort each year slow down the rate of entry of new susceptibles and decrease incidence • This leaves some children susceptible to infection till an older age, leading to a shift in the age distribution of measles towards older children and a lengthening of the interepidemic interval. • This period of low incidence following widespread immunisation is called ‘honeymoon period’ 32
  • 32. Effect of immunization on the epidemiology - 2 • As the cohorts grow older while the disease incidence is low, most persons acquire immunity from exposure to the vaccine rather than to the disease. • If coverage is less than 100%, and the vaccine is less than 100% effective, the incidence will rise after a long lowincidence period, though remaining lower than the preimmunization level with longer IE interval • A dramatic short-term reduction in measles incidence after mass immunization may be followed by the recurrence of measles epidemics, at ever-increasing intervals. 33
  • 33. Effect of immunization on the epidemiology - 3 • In a highly immunized population, a large proportion of cases occur among immunized persons, since there are so few unimmunized persons. – For example, if 98% of the population is immunized with a vaccine that is 95% effective, 71% of cases are predicted to occur among vaccinated persons • In large urban areas, the pool of children who have lost maternal antibodies but have not yet reached the minimum age for immunization contributes to sustaining measles transmission even at high coverage levels. – Vaccines which can be applied at 6 months of age will assist in measles control in areas where measles before the age of 9 months is a significant cause of death 34
  • 34. Effect of immunization on the epidemiology - 4 • Apparent negative effects of immunization programme – Outbreaks occurring after raised coverage may lead to a loss of confidence in immunization programme among health workers, the public and political leaders. – In countries with poorly developed surveillance prior to the immunization programme the reported measles cases may even increase as the programmes get stronger, because of increased completeness of reporting. 35
  • 35. Effect of immunization on the epidemiology - 5 • Although measles out-breaks have begun to occur in older children in some countries with high coverage, this is an expected consequence of an immunization programme whose target age group has been children under 2 years • Another expected result of high coverage levels is an increase in the proportion (but not the rate) of cases among previously immunized children • The occurrence of either of these does not necessarily indicate programme failure. • But still EPI has reduced measles incidence and mortality rates 36
  • 36. Experience from USA & Africa • In response to the resurgence of measles, the USA has launched an initiative to increase age-appropriate immunization coverage, targeted to inner-city areas, and has recommended a routine second dose of measles vaccine at school age, to protect the 2-5% of persons who did not respond to initial dose of vaccine • However, in some large cities in Africa, measles in children under 9 months old remains a major problem despite higher coverage rates and has led to renewed interest in lowering the age for routine measles immunization. 37
  • 37. Epidemiology of measles in India – early years of vaccination • The age of peak measles incidence in India was 1-2 years. • Generally, occurs at a younger age in urban areas where transmission is continuous as compared to rural areas where measles is intermittent • Endemic measles primarily occurs during the spring with incidence starting to increase from January till April with peak in March. • However Epidemics have occurred any time during the year • Reported CFR from 1-3% while fatality rates among hospitalized children as expected is much higher 15-20% • One of the factors contributing to mortality is the reluctance of the village people to seek treatment for complications because of strong traditional beliefs. • Vaccine efficacy studies – range of 80% to 100% 38
  • 38. Herd immunity in measles • Immunization programmes aim to interrupt measles transmission by inducing herd immunity • The high transmissibility of measles makes herd immunity difficult to achieve. • Hope-Simpson estimated that 75.6% of household exposures of susceptibles lead to measles transmission, compared to 61% for varicella and only 31.1% for mumps • It has been estimated that around 95% immunization coverage with a vaccine which is 100% effective must be achieved to eliminate measles from a stable population. 39
  • 39. Outline • • • • • • • • • • Terminology History Burden The disease Epidemiology The vaccine Measles control in India Surveillance Measles and MGD 4 Feasibility of eradication 40
  • 40. Vaccine In the USA • 1963 – killed and live attenuated (Edmonston B strain) vaccine licensed • 1965 – live attenuated (Schwarz strain) • 1967 – killed vaccine withdrawn • 1968 – live attenuated s (Edmonston-Enders strain) • 1971 – combined MMR vaccine licensed • 2005 – combined MMRV vaccine licensed 41
  • 41. Measles vaccine in India • Edmonston-Zagreb strain • Grown on human diploid cells or purified chick embryo cells. • Each dose contains at least 1000 infective units and has no preservative. Freeze-dried in single dose or multi dose vials with distilled water as diluent. • Stored frozen or at 2 to 8°C (shelf life 2 years). • Reconstituted vaccine – destroyed by light, heat labile, susceptible to contamination as it does not have any preservative – protected from light, kept at 2 to 8° C and used within 4-6 hours of reconstitution • Dose - 0.5 ml S.C/IM preferably over the upper arm/anterolateral thigh 42
  • 42. Immunisation responses • Antibodies develop in 95% of children vaccinated at 12 months of age and 98% of children vaccinated at 15 months • Sero-conversion rates are similar for single-antigen measles vaccine, MMR, and MMRV • Approximately 2%–5% of children who receive only one dose of MMR vaccine fail to respond to it (i.e., primary vaccine failure) • Most persons who fail to respond to the first dose will respond to a second dose. • Serologic and epidemiologic evidence indicate that vaccine-induced immunity appears to be long-term and probably lifelong • Schedule in the USA – First dose of MMR at 12 to 15 months – Second dose at 4 to 6 years (school entry) or any time after 4 weeks of first dose 43
  • 43. Post-exposure prophylaxis • Live measles vaccine provides permanent protection and may prevent disease if given within 72 hours of exposure • Immune globulin (IG) may prevent or modify disease and provide temporary protection if given within 6 days of exposure • IG may be especially indicated for susceptible household contacts of measles patients, esp. contacts younger than 1 year of age 44
  • 44. CI to immunisation • • • • • • Allergy to prior dose Pregnancy Immunosuppression Moderate or severe acute illness Personal or family history of seizures of any aetiology Patients who are severely immuno-compromised for any reason should not be given MMR vaccine • HIV – MMR can be given for asymptomatic and mildly symptomatic HIV infection, not for severe immunosupression 45
  • 45. AEFI • Mild pain and tenderness may occur at the site of injection • Fever of at least 39.4 C occurs in 5% of recipients 7– 12 days following measles vaccination, and a transient rash occurs in approximately 2% of recipients • Thrombocytopenia, allergic reactions 46
  • 46. Vaccine cost effectiveness • Separate studies in Africa and South-East Asia found that adding measles vaccine to a child health intervention package was highly cost effective. • Where routine immunization coverage is low, SIAs or mobile outreach services cost <US$ 100 per additional case averted when compared with administering a single routine dose alone. • Dayan GH et al. Cost-effectiveness of three different vaccination strategies against measles in Zambian children. Vaccine, 2004, 22:475– 484. • Van Damme W, Van Lerberghe W. Strengthening health services to control epidemics: empirical evidence from Guinea on its costeffectiveness. Tropical Medicine and International Health, 2004, 9:281–291. • Vijayaraghavan M et al. Economic evaluation of measles catch-up and follow-up campaigns in Afghanistan in 2002 and 2003. Disasters, 2006, 30:256–269. • Commission on Macroeconomics and Health. Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. Geneva, World Health Organization, 2001. • Edejer TT et al. Cost effectiveness analysis of strategies for child health in developing countries. British Medical Journal, 2005, 331:1177 47
  • 47. WHO position paper on vaccine – 1/2 • Recommended for all susceptible children and adults without contraindications • All children with 2 doses of measles vaccine should be the standard for all national immunization programmes • Reaching and maintaining high immunization coverage remains the cornerstone • Optimal age for MCV1 – In countries with ongoing transmission - 9 months – In countries with low transmission - 12 months • MCV2 may be added to the routine immunization in countries with ≥80% coverage of MCV1 at the national level for 3 consecutive years • Countries that do not meet this criterion should prioritize improving MCV1 coverage and conducting high quality follow-up SIAs 48
  • 48. WHO position paper on vaccine – 2/2 • Optimal timing of routine delivery of MCV2 – Countries with MCV1 delivered at age 9 months, should administer routine MCV2 at age 15–18 months – In countries with low measles transmission where MCV1 is administered at 12 months, the optimal age for delivering routine MCV2 is based on programmatic considerations (either 15-18 months or school entry) • Criteria for stopping follow-up SIAs – >90–95% immunization coverage at the national level for both MCV1 and routine MCV2 as determined for a period of at least 3 consecutive years. 49
  • 49. Outline • • • • • • • • • • Terminology History Burden The disease Epidemiology The vaccine Measles control in India Surveillance Measles and MGD 4 Feasibility of eradication 51
  • 50. Measles control in India 52
  • 51. Control achieved by SEAR • The South-East Asia Region (SEAR) has a goal of 90% reduction in measles mortality by 2010 in comparison to 2000 estimates • Achieved by all countries in the region except India by 2008 • Including India, overall mortality reduction only reached 46%, with routine coverage up to 75% (2008) from 61% (2000) 53
  • 52. Coverage with 1 dose of measles-containing vaccine among children aged 12–23 months, by district — India, 2007–2008* • DLHS 3 reports a coverage of 69.6% for MCV1 • CES 2009 reported a coverage of 74.1% for MCV1 54
  • 53. Trends in MCV1 coverage in India 55
  • 54. Initial steps • Little information is available about measles epidemiology in India. • Reliable surveillance data are missing and few outbreaks are investigated. • India is setting up surveillance for outbreak prevention while continuing to address the challenges of measles control. • In 2005, a national strategic plan was formulated. 56
  • 55. Multi-year strategic plan India: 2005-10 • Addresses the issue of reducing the measles mortality by twothirds by 2010, compared to 2000. • To achieve at least 90% coverage in 80% of the districts of the country by 2009 and collection and use of good quality epidemiological data from active surveillance and outbreak investigation • Challenges: Ensuring societal and political support, ensuring adequate supplies of measles vaccine of assured quality • As per the draft comprehensive Multi Year Strategic Plan (cMYP, 2010-17) for immunization aims to reduce by 90% mortality by 2013 as compared to 2000. • Prior to 2010, India was the only country that had not introduced a 2nd dose 57
  • 56. Global Context: Worldwide measles vaccination delivery strategies - 2010 MCV1 & MCV2, no SIAs (40 member states or 21%) India national immunization programmeintroduced second dose of measles in 2010 Data source: WHO/IVB measles database as of 26 January 2010 MCV1, MCV2 & one-time catch-up (36 member states or 19%) MCV1, MCV2 & regular SIAs (57 member states or 28%) MCV1 & regular SIAs (59 member states or 31%) Single dose (1 member state or 1%) 58
  • 57. Key Strategies for Measles Mortality Reduction 1. High coverage of measles 1st dose 2. Sensitive laboratory supported surveillance 3. Case management including vitamin A supplementation 4. 2nd opportunity for vaccination There are 2 ways of providing 2nd opportunity they are a. Routine 2nd dose of measles b. Supplementary Immunization Activity (SIA) for measles Source: Measles Mortality Reduction – India Strategic Plan 2005-10 59
  • 58. Monitoring • Indicators to monitor the implementation of measles control strategies at State and National levels – Number of States with measles plan of action – Annual number of reported measles cases and deaths nationally, by States and districts – Percentage of outbreaks investigated by States – Percentage of known outbreaks confirmed serologically – Measles immunization coverage – State & District level – Percentage of districts with routine measles coverage <50%, 50-79%, 80-90%, 90%+ – Coverage of SIAs- State & District level – Percentage of districts with mass campaign coverage level <80%; 80-90% and >=90% – Completeness and timeliness of monthly surveillance reports 60
  • 59. Rationale for Measles Catch-up Campaign • Analysis of measles outbreak data for the period 2006 to 2009, in states with outbreak surveillance reveals that around 90% of the measles cases were in the age group of <10 years • As measles vaccination does not confer 100% protection and seroconversion rate is only 85% when given at 9 months of age, a substantial number of children remain unprotected even if they are vaccinated • Measles catch-up campaign is required to sustain high measles vaccination coverage and also for providing a second opportunity for the unprotected children 61
  • 60. Rationale for second dose • 40% of India’s annual birth cohort of 26 million children remain susceptible to measles – Routine measles vaccination coverage - 70% – Vaccine effectiveness(single dose,9 months) - 85% – Real protection to measles = 60% (0.70 × 0.85=0.60) • Immunological - immunize the primary vaccine failures (those children who failed to respond to the first dose) • Programmatic - to vaccinate those children who were missed by routine services • Most children who have failed to respond to the first dose of MCV respond well to a second dose* • Two doses of measles vaccine highly cost effective # *World # Health Organization, Measles vaccines: WHO position paper. Wkly Epidemiological Rec. 2009; 84 World Health Organization, Measles vaccines: WHO position paper. Wkly Epidemiological Rec. 2009 62
  • 61. Recommendations from expert Indian committees • National Technical Advisory Group on Immunization (NTAGI) recommended: 1. States with MCV1 coverage <80%: Second opportunity for measles vaccine through measles catch-up campaigns in 9 months - 10 years age 2. States with MCV1 coverage >80%: MCV2 through routine immunization at 16-24 months of age • Ad hoc expert review committee reviewed above strategy in early 2010 and endorsed the NTAGI recommendation • 21 states qualify for MCV2 through RI and 14 states qualify for large scale catch-up campaigns • Of these 21 states, 4 states/UTs (Delhi, Goa, Puducherry and Sikkim) are already using second dose of measles in their RI (MMR) 63
  • 62. Introduction of MCV2 • Decision to introduce 2nd dose measles vaccination -the draft comprehensive Multi Year Strategic Immunization Plan of the Government of India (cMYP 2010-2017) • May 2010 -GOI announced its decision to implement NTAGI recommendation to introduce MCV2# * Measles Catch Up Immunization Campaign- Guidelines for Planning and Implementation. June 2010 Ministry of Health and Family Welfare, Government of India. and Recommendations of National Technical Advisory Group on Immunization (NTAGI), 16th June 2008, Ministry of Health and Family Welfare, Government of India. #Minutes 64
  • 63. Age for second dose • 90% of confirmed measles outbreak occur in states with low MCV1 coverage (<80%) are among children less than 10 years of age* • Hence, measles catch-up campaigns target children 9 months to 10 years of age in the 14 states *Measles Catch Up Immunization Campaign- Guidelines for Planning and Implementation. June 2010 Ministry of Health and Family Welfare, Government of India. 66
  • 64. State-specific delivery strategies • 14 states with measles coverage< 80% – (Arunanchal Pradesh, Assam, Bihar, Chattisgarh, Gujarat, Haryana, Jhark hand, M.P, Manipur, Meghalaya, Nagaland, Rajasthan, Trip ura and U.P) – will introduce MCV2 through catch-up vaccination campaigns • In the remaining 21 states with better performing routine immunization systems (i.e.,>=80% routine measles coverage) • Delhi, Goa,Puducherry and Sikkim- already use 2nd dose measles vaccine in their RI program (as MMR) • Phase 1 measles catch-up campaign commenced in November 2010 67
  • 65. MCV2 introduction: State-specific delivery strategies SIA: MCV1 <80%: 14 states RI: MCV1 >80%: 21 states 68
  • 66. Measles SIA - India 69
  • 67. MCUP: Basic considerations • All children in target age-group (9 mo-<10 years) to be vaccinated – Irrespective of previous doses of measles vaccine received – Irrespective of prior history of measles disease • In general, this age group constitutes around 18-25% of the total population – Target: ~135 million children – Expected coverage: More than 90% (evaluated coverage) • Massive public health undertaking with an injectable vaccine • Both safety and high coverage are critical • MOH&FW decided to take a phased approach 70
  • 68. MCUP: Basic operational strategy • • • • All immunizations from static posts (no HTH immunization) Regular routine immunization sessions will be conducted without interruption – Two regular routine immunization clinics per week – Measles catch-up campaign in remaining four days Average Campaign duration: 3 weeks = 12 working days – 1st week: School based campaign (for 5-10 year children) – 2nd & 3rd weeks: Community based campaign for non-school going children or children missed during school week Training – Only trained persons (ANMs) will work as vaccinators – All ASHA/ AWW will be trained for beneficiary listing and Interpersonal communication – Doctors (including clinicians in pvt. sector) have been trained in managing rare adverse events, if any 71
  • 69. MCUP: session sites and teams • Types of session sites – Session sites at Educational Institutes – Outreach site (regular RI sites and additional sites in village/urban mohalla) – Mobile/Special team – Facility based session site • Team composition – 1-2 Auxiliary Nurse Midwife (ANMs) – ASHA (Accredited Social Health Activist) – AWW (Anganwadi Worker) – Volunteer 72
  • 70. Overview of Measles SIA J A M M U & K A S H M IR HI M A C H A L PR AD ES H P U NJ A B C H A N D IG A R H UT T A R A K HA N D HA RY A N A DE LH I A R UN A C H A L P R . S IK K IM UT T A R P RA DE S H RA J A S T H A N ASSA M NA G A L A N D B IH A R M E G HA LA Y A M A N IP U R J HA RK HA N D G UJ A R A T MAD H YA PR AD ESH TR IP U R A W EST B EN G AL M IZ O R A M Phase 1, 45 districts covered (~ 13 million) Phase 2, 152 districts covered (~ 40 million) C H H A T T IS G A R H O RI S S A D A M A N & D IU D& N HA V E L I Phase 3, 167 districts planned (~ 81 million) M A H A R A S H TR A A N DH R A P RA D E S H P O N D IC H E R R Y KAR N ATAKA GOA A & N IS L A N D S LA K S H A D W E E P TA M IL N A D U KER AL A Target population:  ~ 135 million children 9 months – 10 years of age  365 districts in 14 states Phase 1 in 2010 -11; Phase 2 in 2011-12; Phase 3 in 2012-13 Starting Sep 12 73
  • 71. Measles SIA phasing plan, India Total number of Districts Districts covered in Phase 1 Districts covered in Phase 2 ARUNACHAL PR. 16 1 15 ASSAM 26 1 25 BIHAR 38 5 15 CHHATTISGARH 18 9 9 GUJARAT 32 5 5 HARYANA 21 5 16 JHARKHAND 24 5 19 MADHYA PRADESH 50 5 13 MANIPUR 9 1 8 MEGHALAYA 7 1 6 NAGALAND 11 1 10 RAJASTHAN 33 5 5 TRIPURA 4 1 3 UTTAR PRADESH 75 State Number of Districts for Phase 3 18 22 32 23 3 72 Total 364 45 152 167 Target Population ~134,000,000 13,845,686 40,167,580 ~81,000,000 12,076,836 (87.2%) 36,102,564 (89.9%) Coverage (% Achieved) 74
  • 72. Coverage achieved: Administrative and RCA monitoring (MCUP Phase 1 & 2) 48,179,400 of 54,013,266 vaccinated (89.2%) 98 of 197 districts with >= 90% coverage Number of Children monitored 2465 22438 287758 31462 49174 132343 140880 181299 160 3308 2175 41846 3280 27867 75
  • 73. Campaign awareness & source of information (in %) 100 94.9 90 83.7 80 • 70 • 60 • 50 40 Vast majority of those monitored were aware of the campaign Session sites with visible IEC material – 82.6% Sites where social mobilization was being done by house visits – 88.3% 30 16.4 20 7.7 10 0 Awarness for the campaign Health worker/ ASHA/AWW N= 638,660 children monitored Teachers Family members/ Community 5.3 Newspaper/ Poster/ Banner 1.4 TV/Radio/Miking 76
  • 74. Reasons for missing vaccination during Measles catch-up campaigns-India (RCA) Social mobilisation Operational 52% 44% 4% (N – 87,197) Others Social mobilisation includes •Parents didn’t know of campaigns, •Didn’t know about Place/Date, •Didn't give Importance •Fear of Injection & AEFI Operational • No vaccine/logistics • No vaccinator •Site too far, long queue Others •Family travelling, sick child, •Gone to School etc 77
  • 75. All State Governments have issued orders to include Measles 2nd dose under RI in campaign districts after 6 months 78
  • 76. Measles SIA timeline (3rd phase) MADHYA PRADESH Period of campaign Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb -13 Mar -13 Apr-13 GUJARAT RAJASTHAN BIHAR UTTAR PRADESH No. of Districts 12 (17 Sep) 22 (13 Sep) 9 (17 Sep) 7 8 5 8 6 18 22 16 11 23 79
  • 77. Summary of measles 2nd dose • Measles 2nd dose under RI at 16-24 months introduced in 21 States/UTs in 2010 • Measles SIA completed in 197 districts in 14 states with coverage of 90% in two phases. • In 9 states out of 14 completed measles SIA in all districts. • 2nd dose of measles under RI started 6 month after measles SIA • Remaining 167 districts in 5 states planned/ on going measles SIA during 2012-13 with target of 81 million children (UP, MP, BI, RAJ, GUJ) • Case based surveillance, expansion of laboratory network, • MEASLES 2ND DOSE WILL BE UNIVERASLIZED IN THE ENTIRE COUNTRY BY 2014 80
  • 78. Impact on measles transmission [Data as on August 2012] 81
  • 79. Measles cases and outbreaks in districts completed catch-up campaigns and lab supported measles surveillance before and after start of MCUP Pre-MCUP Surveillance data from MCUP districts* State MCUP Phase & (No. of districts covered) Reference period (From) 2 (26) Bihar 1 (5) 07-2011 NA 7 MCUP activity completed by MM-YYYY Total number of confirmed measles outbreaks Total number of confirmed measles cases 12-2010 12-2011 0 0 353 06-2012 08-2012 0 0 NA 1 (1) Assam Total number of confirmed measles cases NA MM-YYYY Total number confirmed measles outbreaks Post-MCUP Surveillance data from MCUP districts # NA 01-2011 01-2012 0 0 MM-YYYY Reference period (until) 2 (15) 06-2011 2 82 02-2012 08-2012 0 0 1 (5) 07-2010 14 546 07-2011 07-2012 0 0 2 (5) 03-2011 1 15 03-2012 08-2012 0 0 NA NA 03-2011 03-2012 0 0 Gujarat Jharkhand 1 (5) 2 (19) 7 238 03-2012 08-2012 0 0 1 (5) 07-2010 5 354 01-2011 01-2012 0 0 2 (13) 01-2011 8 492 01-2012 08-2012 0 0 1 (5) 12-2009 4 211 12-2010 12-2011 2 54 2 (5) Madhya Pradesh 07-2011 03-2011 3 60 03-2012 08-2012 0 0 1 ( 26) 23 1111 2 54 2 (83) 28 1240 0 0 Rajasthan Grand Total 82 Data as on 13/08/2012
  • 80. Summary of MCV2 by SIA and RI • Of 14 states implementing measles SIA, 6 states (Assam, Bihar, Gujarat, Jharkhand, MP & Rajasthan) have lab supported measles surveillance data to make before-after comparisons – The ‘post’ window for phase-2 activity is <1 year (Range: 1-7 months) for all states, Surveillance sensitivity is variable across states and should be taken into account while interpreting results, Quality of MCUP activities have also varied among states • Overall the MCUP strategy has been effective in reducing measles transmission • In measles 2nd dose states the size and frequency of measles outbreak reduced • Overall, in phase 1 & 2 districts SIA Outbreaks Measles cases Upto 1 yr before SIA 51 2351 Upto 1 yr after SIA 2 54 83
  • 81. Outline • • • • • • • • • • Terminology History Burden The disease Epidemiology The vaccine Measles control in India Surveillance Measles and MGD 4 Feasibility of eradication 84
  • 82. NPSP assisted measles surveillance Each state supported by a WHOaccredited lab Year surveillance initiated 2006 2007 2009 2010 2011 85
  • 83. Objectives of measles surveillance • • • • Detect and investigate outbreaks Identify high risk populations/areas Strengthen vaccine coverage in these areas Monitor reduction in mortality and morbidity 86
  • 84. Components of surveillance • • • • Reporting network – RU and informers Data flow and analysis Investigation and confirmation of outbreak Consolidation of data at distt. and state level to decide immunisation strategy 87
  • 85. Reporting network • All sites that are currently reporting AFP cases – RUs: govt., and pvt., health facilities treating a large no. of under 15 children – medical colleges, distt. Hospitals, CHC, PHC – Informers: smaller facilities and clinicians • Additional sources – IDSP 88
  • 86. Reporting cases • Who reports – all RUs and informers • What – clinical measles cases • When – RUs: weekly (mondays), informers: as and when • How - weekly reporting format (VPD-H002) • To whom – DIO • Nil report to be sent by RUs if no case is seen 89
  • 87. Case definition • Any person in whom clinician suspects measles Or • Any person with fever and maculopapular rash with cough, coryza or conjunctivitis • For epidemiological investigation, clinical measles would be a case within last 3 months 90
  • 88. Triggers for investigation outbreak • >= 5 clinical cases in a block in a week Or • >= 1 death due to measles in a block in a week Or • >= 5 clinical cases in an area bordering several blocks 91
  • 89. Outbreak investigation • Visit area – To confirm whether looks like measles – Presence of number of cases • Collect detailed information from the community • Collect blood from 5 cases with rash onest within 4 to 28 days • Decide on level of response – Strengthening of immunisation – Proper case management • Confirmation of outbreak by positive measles IgM in any 5 samples collected 92
  • 90. Planning for outbreak investigation – 1/2 • Before – Formation and orientation of Epidemic Response Team (ERT) – At distt. level – Members : DM&HO, DIO, program officer (IDSP), Statistical officer and surveillance medical officer (SMO) – The MO may be included – Role of ERT • To plan and guide investigation • Monitor progress in data collection, compile and analyse data and give final report • SMO is the technical guide 93
  • 91. Planning for outbreak investigation – 2/2 • During – – – – – – – – – – – – Identifying potential outbreak Confirming outbreak and assigning a number Mobilisation of ERT Orientation and planning meeting at local level Conducting measles case search Collection and shipment of specimens to lab Lab confirmation Data analysis Conversion of data into information for action Report writing Feedback Initiating actions 94
  • 92. Measles outbreak surveillance - 1 • Suspected Measles cases reported weekly from AFP reporting units - built on strong AFP reporting network • Data compiled at District to identify large outbreaks • IDSP reports included • Epidemic Response Team (ERT) and the EPI team in • District decide on house-to-house search for cases • Larger outbreaks investigated with serological testing • Field investigation including case age and immunization status • Serologic confirmation (5 cases) • Treatment (Vitamin-A, Antibiotics, ORS) The National Polio Surveillance Project - India 95
  • 93. Measles outbreak surveillance - 2 • Government functionaries involved at all stages – ERT members: DIO/DSO/CMOH/others: – Field Investigation: Local public health staff – Sample collection and transport: Local facility lab staff • NPSP SMO: Many support multiple districts – Trains District and Block Medical Officers – Coordinates sample collection and shipment, – Coordinates data compilation and flow • NPSP (Central and Regional level): – Cross-check quality of data – Monthly Bulletin - shared with GOI, states, partners The National Polio Surveillance Project - India 96
  • 94. Clinical measles cases, 2005-2011*, India Andhra Pradesh, Assam, Bihar, Gujarat, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Rajasthan, Tamil Nadu and West Bengal N D J F M A M J J A S ON D 2005 J F M AM J J A S ON D J F M AM J J A S ON D 2006 2007 J F M AM J J A S ON D J F M AM J J A S ON D J F M AM J J A 2008 2009 2010 97
  • 95. Serologically confirmed measles, rubella or mixed (Andhra Pradesh, Assam, Bihar, Gujarat, Jharkhand, Karnataka, Kerala, Madhya Pradesh, 152 outbreaks Measles outbreaks confirmed Rubella outbreaks confirmed Mixed outbreaks confirmed 98
  • 96. Serologically confirmed measles outbreaks Vaccination status of measles cases by age, 2010, India 4000 Total cases- 8,984 3500 3000 2500 2000 1500 1000 500 0 < 1 yr 1-4 yr Vaccinated 5-9 yr Not Vaccinated 10-14 yr >= 15 yr Unknown *Cases from serologically confirmed measles outbreaks 99
  • 97. Performance indicators for surveillance • • Control stage for countries where measles is endemic – Target: all indicators to be >80% – % of districts reporting monthly; – % of districts reporting within a month after the report period; – % of reported cases containing core data (i.e. age, vaccination status). – These indicators should be evaluated at least monthly. In countries where weekly – reporting is established, weekly evaluation of indicators may be preferred. For countries at the low incidence or elimination stage, weekly basis. – Performance indicators: Target: all indicators to be >80% – % of sites reporting weekly – % of cases notified within <48 hours of onset of rash – % of cases investigated within <48 hours of notification – % of cases with adequate specimen and laboratory results within 7 days – % of confirmed cases with sources of infection identified 100
  • 99. Definitions • Clinical case description: Any person with – Fever and – Maculo-popular rash lasting for more than 3 days – Cough or coryza or conjunctivitisLaboratory criteria for diagnosis: – At least a four fold increase in the anti body titre or – Isolation of measles virus or – Presence of measles specific IgM anti bodies • Case classification – Suspect case: Any case with fever & rash – Probable case: Any suspect case who is diagnosed as measles by MO on basis of clinical case description – Confirmed case: A case that meets the clinical case definition and that is Laboratory confirmed or linked epidemiological to a lab confirmed case 102
  • 100. Response triggers • Trigger Level-1 (Suspected limited outbreak, local response) – A single case of measles in a tribal area – More than 2 cases of fever with rash in a village/geographical area of 1000 population • Trigger Level-2 (Epidemic, local & regional response) – More than 4 cases of fever with rash in a geographical area of 1000 population – Similar illness in more than 1 village reported in the same week 103
  • 101. Outline • • • • • • • • • • Terminology History Burden The disease Epidemiology The vaccine Measles control in India Surveillance Measles and MDG 4 Feasibility of eradication 104
  • 102. Measles and MDG 4 • From 2000 to 2008, child mortality decreased by 1.6 million, from an estimated 10.4 million to 8.8 million deaths; • During the same period measles deaths declined by over 0.5 million (31% of total) suggesting that the decline in measles has played a part in the overall decline in child mortality. • Measles directly contributes to the reduction of under-five child mortality and hence to the achievement of Millennium Development Goal number 4. • Improving measles vaccination coverage and reducing measles-related deaths is a global imperative, particularly as it relates to MDG 4 105
  • 103. Overview of Key Statistics, 2000-2009 • Global routine measles vaccination coverage reached 83% in 2008, up from 71% in 2000. • Measles vaccination prevented over 12.7 million deaths globally over 2000-2008 • Between 2000 and 2008, global measles mortality decreased by 78% from 733,000 deaths in 2000 to 164,000 in 2008. – – – – Africa: 92% Eastern Mediterranean: 93% South-East Asia: 46% (80% if India is excluded) Western Pacific: 92% 106
  • 104. Outline • • • • • • • • • • Terminology History Burden The disease Epidemiology The vaccine Measles control in India Surveillance Measles and MGD 4 Feasibility of eradication 107
  • 105. Feasibility of global eradication 108
  • 106. Global goals • A 95% global mortality reduction goal by 2015 (compared with 2000) was adopted by the WHO World Health Assembly in May 2010 109
  • 107. Goal for measles elimination - SEAR • At a regional measles consultation in New Delhi in August 2009 – all Member States agreed that regional measles elimination was technically, biologically and programmatically feasible – Eight countries (Bangladesh, Bhutan, Indonesia, Nepal, Thailand, Myanmar, Maldives and Sri Lanka) agreed to set a goal for achieving measles elimination by 2015 – Timor-Leste set a goal of 2020 – India did not set a target year for elimination goal 110
  • 108. Feasibility • Discussed since the introduction of vaccine • 3 criteria – humans must be crucial for transmission – sensitive and specific diagnostic tools – effective intervention • Many experts believe this is met by measles • Eradicating measles by 2020 is projected to cost an additional discounted $7.8 billion and avert a discounted 346 million DALYs between 2010 and 2050* *Ann Levin et al.Global Eradication of Measles: An Epidemiologic and Economic Evaluation. JID 2011:204 (Suppl 1) 111
  • 109. Biological feasibility • • • • No non-human reservoirs Readily diagnosed after the onset of a rash Virus has not mutated Limitations – Highly contagious, R o of 12 to 18 as compared to 5-7 for smallpox – Requires high level of population immunity to interrupt transmission – Contagious for several days prior to onset of rash – Possibility of transmission from subclinical cases – HIV epidemic – prolonged transmission: unlikely to hinder 112
  • 110. Technical feasibility • Vaccine is safe, effective • Limitations – Inactivated by light and heat – Strict cold chain must be maintained – injected SC or IM necessitating trained healthcare workers, needles, syringes and the proper disposal of hazardous waste – Maternally antibodies and immunological immaturity reduce the protective efficacy in early infancy 113
  • 111. Logistical feasibility • Two broad strategies – In countries with sufficient infrastructure, the second dose through routine immunization – In others, mass-immunization campaigns - Catch-Up, Keep-Up, FollowUp and Mop-Up • War and displaced popualtions • Loss of public confidence - religious or philosophical grounds • New tools - inexpensive, safe, heat-stable, immunogenic in very young, single dose without the need to use a needle or syringe 114
  • 112. Prospects for global elimination • Elimination of measles in large areas, such as the Americas, suggests that global measles elimination is feasible • Political and public support necessary – difficult in rich countries • Critics claim – diversion of resources from primary care and vested foreign interests • Serious discussion of measles eradication will probably take place after polio eradication 115
  • 113. WHO position on eradication • WHO global technical consultation to assess the feasibility of measles eradication, 2010 • The group concluded that measles can and should be eradicated • 
Milestones to eradication – MCV1 Coverage of 90% at national level and 80% in all districts – Incidence of <5 cases/million population – Atleast 95% reduction compared to 2000 • Target dates for elimination region wise – European 
and 
Eastern
 Mediterranean – 2015, WP – 2012, Afrcian – 2020, SEAR – 2020 • Eradication target to be set yet 116
  • 114. Conclusion • Controls efforts have reduced measles related morbidity and mortality, esp. due to availability of an effective vaccine • Selected regions of the world like India need concentrated efforts • Measles eradication is a real possibility but will require greater commitment from all stakeholders 117