MEASLES RUBELLA OUTBREAK SURVEILLANCE

1. Measles and Rubella
Outbreak Surveillance

2. Roadmap to MR Elimination in India
Goal: Achieving and Sustaining Measles and Rubella Elimination in India

3. 3
GOI Communication for Outbreak Response
GOI Communication to State regarding lab
confirmed measles outbreaks and necessary public
health response actions to be taken
Key Highlights:
• Urgent need to plan towards increasing the
uptake of MR vaccination through social
mobilization and addressing vaccine hesitancy.
• STFI and DTFI meetings must be conducted on
regular basis and provide strategic directions to
focus on areas needing attention.

4. 4
Special GOI Advisory for Measles Outbreak Response
GOI special advisory to State on Measles Outbreaks and response
Subsequent to rapid increase in measles incidence and measles
outbreaks, a special advisory has been shared on 23rd November
2022, towards covering missed out/dropped out beneficiaries and
administering additional dose of measles and rubella containing
vaccine (MRCV) to eligible beneficiaries on outbreak response
immunization (ORI) mode.

5. National Advisory on MRCV dose in Special situation

6. Investigation of each reported
case using MR-CIF
Notification
Modified MR Surveillance ( Case-based & Outbreak) Algorithm
Suspected Measles Case Reporting sites – Medical College, GH, Pvt
Paediatrician, PHC, informers, Community Health
Worker
RU -Weekly Report along with AFP
Sample Collection Designated MR Laboratory
Cold Chain
Desk review of MR data in
weekly meetings (BWR / DWR)
Flag outbreaks with 5 cases in a
block/ward or 1 death in 4weeks
If clustering, conduct detailed
outbreak investigation as per
existing protocols
Serum Sample from 5 cases ( ≤ 28
days) & Throat / urine sample from
2 cases ( ≤ 7 days)
Cold Chain
Outbreak ID and Preliminary Inv
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7. Desk Review of MR Data at District level
Different Sources of reporting suspected measles case*
IDSP
(S, P and L Form )
VPD H002 from
RUs
Directly
reported by
IUs which are
part of
reporting
network
Media or
private
practitioners
not part of
reporting
network
≥ 5 suspected measles cases reported within a 4
week period in a block/ward/planning unit or ≥ 1
suspected measles death(s) is reported
Flag an outbreak and assign outbreak ID
*Once a month, HMIS will be considered as a source of
reporting/cross verifying suspected measles cases

8. Preliminary Search
Initiated in all
outbreaks which
are flagged
Preliminary search
should be carried
within 72 hrs. of
outbreak flagged
ASHA/AWW under the
supervision
of ANM
Scan surrounding
houses/faith healers/
Anganwadi/school
ASHA/ANM will capture
information
Action following outcome of Preliminary Search
• If there is clustering of suspected measles cases - Proceed for detailed outbreak investigation
• If there is no clustering or cases found with vesicular rash - No further investigation required

9. MR OB RESPONSE AND CONFIRMATION
Clustering of cases in a village/mohalla and
maculopapular rash
≥ 2 positive measles or rubella cases in the past four consecutive weeks
OB Confirmation
From Weekly Reporting/any other source
≥ 5 suspected measles cases reported in a block/ward/planning unit in the past four consecutive weeks or
≥ 1 suspected measles death
No clustering of cases /
vesicular rash
Detailed investigation
following ERT activation
No further
investigation
Flag outbreak ID
Sample
collection
Preliminary search
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Clinical case
management
Active case searches in
the community
( OB003 )

10. Definition of a Suspected Outbreak:
A suspected measles outbreak will be flagged with an outbreak ID when
there are:
≥ 5 suspected
measles cases
reported in
block/ward in four
weeks duration
OR
• ≥5 suspected
cases in an area
bordering multiple
contiguous
blocks/ward in 4
weeks duration
OR
• ≥ 1 suspected
measles-death
in a block/ward
in 4 weeks
duration

11. Objectives of MR outbreak investigation
• Early detection and response
• Rapid implementation of control measures- reduce extent of disease
spread, reduce mortality and morbidity
• Study the epidemiology – disease dynamics and areas of low
immunity
• Improve surveillance

12. 12
Strengthen Outbreak Response
An outbreak of measles or rubella indicates both an immunity gap and a need to
strengthen surveillance.
Implementation of Revised Outbreak Protocol

13. Detailed Investigation
• MOIC / MO will review the data from preliminary investigation to
identify clustering of suspected cases
• Inform the DIO about the findings
• Epidemic response team (ERT) will be activated by DIO with an
oversight of DSO & SMO. It comprises of
o Block Medical Officer (BMO) ; Medical Officer in Charge (MOIC) of planning unit ; Hospital clinician /
physician / pediatrician ; Health supervisor ; Public Health Nurse (PHN) ; Pharmacist ; Laboratory
representative ; NGO representative/ community leader
• MOIC to conduct pre-orientation meeting of field staff for
community search
• Analyze prior epidemiological data to guide the public health
response to prevent further spread of disease
• Evaluate the immunization coverage - MRCV1 and MRCV2
• Quality of 0 – 5 Yr. Hth Survey , Mobilization plan 13

14. Roles and Responsibilities of ERT
• Identify HR needed for rapid outbreak response on the ground
• Conduct pre-investigation orientation meeting for field staff
• Establish clear lines of responsibility for planned actions
• Ensure availability of logistics required in an OB response
• Analyze epidemiological data to guide the public health response
• Execute plans to prevent further spread of OB
• Evaluate the immunization coverage - especially MRCV1 and MRCV2
• Plan for additional immunization sessions for under or un-immunized
children
• Review and monitor the response
• Evaluate the response
• Provide summary of outbreak
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15. Detailed investigation
15
At village level:
Step 1: Before detailed investigation is initiated,
MOIC / MO and health workers will visit the affected
village:
 inform Panchayat head / sarpanch/ward
member about an outbreak
 explain control measures
 seek support in sensitizing community
 seek his/her assistance to avail the list of
medical practitioners and faith healers within
the village/Mohalla
 Seek support in sample collection

16. ACS in the Community
House to house search
• Look for additional suspected cases in the
village
• Prepare line list for all suspected cases using
revised OB 003
School/Anganwadi search
• Screen all schools and anganwadi
• Sensitize teachers to report
- any case with fever and rash and
- absentees because of fever and rash
- HWs to leave behind contact details for
teachers to report this condition to MOIC
Health worker based: identify any suspected case or measles related
death(s) in past three months in the house and neighborhood
16

17. HTH search during detailed investigation
17
Health team (ANM /ASHA/AWW) will:
 greet the family
 explain the purpose of the visit to the adult family member
 explain about signs and symptoms of the disease
 enquire about suspected measles case in the past 3 months in the house/neighborhood
If yes, further enquire regarding health-seeking behavior
 tactfully explore about death due to measles or its complication in the past 3 months
 to explain the importance of isolation of suspected cases at least four days following
rash onset and to encourage the family to practice the same
 encourage suspected cases with complication to seek medical advice as soon as
possible
 cross check the MCP card for assessing immunization status for MRCV1 and MRCV2, and
other age-appropriate vaccines
 inform when and where they can receive the vaccination

18. Understanding the OB 003
Geographic
location
Outbreak ID
Risk
categorization
Source of
notification of
suspected
cases
EPID NO of
case
Patients details
Age/sex/
religion/caste
Immunization
history
Clinical history
Travel history Complication
Pregnant
women in the
house (if any)
Health seeking
behavior
Details of
samples
collection
Death (if any)
MR OB 003 contains information on

19. VPD OB-003 MR OUTBREAK INVESTIGATION: Information regarding suspected cases
Village/Area: Sub center/Health Post: PHC/UPHC: Team No:
Block/Ward: District: State:
Setting (encircle ): Urban / Rural HRA (encircle) Yes/No If yes: Type of HRA: #
Put code 1 / 2 / 3 / 4 / 5 / 6
Name of ANM & Mobile No: Name of the BMO : Date sent: ____/____/________
Outbreak ID: (To be filled by health supervisor/MOIC) MOB-IND - Date of Notification of INDEX CASE ____/___/_____
Date of Outbreak Investigation: From : ____/____/_______ to ___/____/_____
Source of notification of suspected cases (encircle) Active Case Searches: Community / Health Facility / Passive Surveillance Names of person conducting ACS:
Serial No.
EPID Number*
(not to be
filled by team)
Patient's name,
father's name and address
Sex
Religio
n /
Caste
DOB / Age
Immunization History
(encircle & write date with last
vaccination)
Clinical History
(encircle when
applicable)
Travel
History¤
(outside
district)
Complicatio
ns
Health
seeking
behaviour
after rash
onset
(encircle)
If history of contact with community
workers / influencers after the date of
rash onset, mention details:
Sample
collected
Death
Years Months
Any
pregnant
women in
the house:
Y / N
(if yes note
down the
details of
the
woman)
Specify
categories of
community
contactsᴥ
Date
of
contact
Did they
refer /
report the
case to any
facility
(Y/N)?
If yes,
record
name &
address
Case
notifi
ed by
the
healt
h
facilit
y Y/N
1 _ _ _
Name :
M / F
H /
M /
O
DOB:
¥
MCP Card Available:
Y / N
Fever: Yes / No /
Unknown Any
history
of travel:
Y / N
Encircle
complicatio
ns, if any:
Pnuemonia/
Diarrhoea/
Ear
Infection/
Eye
complicatio
n/ Other
Confined at
home /
Contacted
health
facility /
Contacted
community
worker
Health
worker /
Religious
leader /
Community
influencer
Y / N
(If yes,
please
mention
address)
Y / N
Yes / No
Y /
N
/ U
If yes, date of onset:
Father's/Husband's Name :
Measles containing vaccine Received:
Yes / No / Unknown / NA
If yes, answer below:
Rash: Yes / No / Unknown
If yes , date of onset:
Note,
duration
of travel
is rash
onset 21
days in
past
Name &
Address:
If yes
(encircle):
Serum /
Throat /
Urine /
Nasophary
ngeal
If yes,
date of
death:
First dose:
M / MR / MMR / MMRV
Cough : Yes / No
Grandfather's name: Pregnant
woman:
Y / N
if yes,
mention
name and
EDD
Address : Caste Years: Months: 2nd dose:
M / MR / MMR / MMRV
Coryza : Yes / No
2+ dose:
M / MR / MMR / MMRV
Conjunctivitis : Yes / No
If yes,
name of
the
district:
Type of
health
facility€
G / P / I /
Q / O
Date of
sample
collection:
Date of last MCV/MR vaccine before
onset of rash (dd/mm/yyyy):
Joint pain : Yes / No
Telephone: Enlarged lymph nodeᵠ
:
Yes / No
Vit A phophylaxis after
onset of rash:
Yes / No

20. Clinical Case Management
Appropriate clinical case management of measles and rubella cases is critical to reduce
mortality and prevent further transmission.
Vit A should be administered to all suspected cases of measles irrespective of the timing of previous doses
of Vit A.
If child has clinical ophthalmic signs of Vit A deficiency such as Bitot’s spots, give a third dose four to six
weeks later.
Age
First dose
immediately on
clinical diagnosis
Second dose 24
hrs. apart
Infants <6 months 50,000 IU 50,000 IU
Infants 6-11 months 1,00,000 IU 1,00,000 IU
Children >12 months 2,00,000 IU 2,00,000 IU
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21. Summary of Detailed Investigation
Is conducted once the clustering and non vesicular rash is confirmed in preliminary search
ASAP, after activation of Epidemic Response Team (ERT)
ANM/ASHA/AWW under the supervision Health Supervisor
Establish communication with village head/ward member
Each house of the village/ward should be visited
Additional suspected cases identified during HTH will be captured in OB003 (standard
format for outbreak)
Conduct active case search in anganwadi, school, medical practitioners and faith healers
within the village/mohalla
Sample collection (5 serum and 2 virology- throat swab or urine or nasopharyngeal swab)

22. From a suspected outbreak, two or more lab-confirmed measles
or rubella cases in a block or in an area bordering multiple
contiguous blocks/planning units within a period of 4 weeks.
Two or more
specimens are positive
for measles IgM
Measles outbreak
Two or more
specimens are
positive for rubella
IgM
Rubella outbreak
Two specimens
positive for measles
IgM and two
specimens positive for
rubella
Mixed outbreak
If less than two
specimens positive
for measles or
rubella
Outbreak negative
or discard
Classification of an outbreak
Definition of a Confirmed Outbreak
22

23. MODIFIED OUTBREAK RESPONSE PROTOCOL
Outbreak assessment
Regular monitoring & review
RI strengthening Surveillance strengthening
Line-list additional suspected cases in OB 003
Communication
Passive
surveillance
RI intensification
Active case search in
health facilities within
the affected area
OB confirmation
Intensified
surveillance
Existing OB
response
Addition to OB
response

24. ACS in Health Facilities
Objective: Sensitization of staff and verification
that no suspected measles cases are missed
Visit health facilities under reporting network to
sensitize staff and identify suspected measles
cases through:
• interviews with health staff
• review of hospital records
• discharge diagnosis
ACS within reporting network will be captured with the existing D003.
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25. • During the HTH activity the ANM/ASHA will enlist the potential health
facilities including faith healers and temple sites in her diary
• The list will be maintained in a register at planning unit (CHC/PHC)
• The health supervisor and/or MOIC / MO will visit these potential sites
• Potential informers are informed about ongoing OB, sensitize and motivate
to report suspected MR cases to MOIC or health supervisor
Objective: to increase surveillance sensitivity during an OB
CALL
Informers are requested
to share the details of the
suspected MR case:
name, age, address,
telephone no, and date of
onset of rash
Passive Surveillance
The MOIC / MO will review reported suspect cases at the end of each day through
passive surveillance. 25

26. The ERT may decide to reactivate ACS in the community if there is an increase in
cases from passive surveillance.
Passive
surveillance
Suspected
cases from
OB Area
Case from
Different
Area
Line list additional suspected cases
from OB Area; line list in OB 003
Intensified
Surveillance
Active Case
Searches
(health facility)
Case
Investigation
and Sample
collection as
in CBS
The health supervisor will work closely with passive surveillance sites.
Passive Surveillance
26

27. • Desk review of recent record on Hth survey for children below 5 years (59 months)
with ANM & Mobilisers. E.g. For a 1000 population of village. …. < 5 years children
• Identify dropout and left out children especially for MCV1 & MCV2
• Children found to be unimmunized or under immunized during the line listing in
OB003 will also be due listed for vaccination accordingly
• Line listed beneficiaries will be mobilized to session site on planned date and time
for age-appropriate vaccination. Communication plan…
• May plan an additional RI session as soon as possible preferably within 2-7 days
after detailed investigation, in case of significant unimmunized or under immunized
children
RI Intensification
27

28. Communication
28
Communication plan to be prepared and discussed with DIO & DSO, which will include the
following components:
 Inform and sensitize all stakeholders
 Identify NGOs/civil society organizations working in affected areas and seek their support
 Interpersonal communication training of HWs
 Address rumors and misinformation
 Enhance detection and reporting of suspected measles cases by developing IEC material
(banner/poster/FAQs) for community and health workers in local language
 Print and electronic media handling by identifying media spokesperson, address social
media
 Preparing press notes

29. MR Outbreak Classification

30. Criterion Classification
>= 2 measles and >= 2 rubella positive Mixed outbreak
>= 2 measles positive Measles outbreak
>= 2 rubella positive Rubella outbreak
< 2 measles and / or < 2 rubella positive Negative
Outbreak classification-with >=5 cases having Serum / Virology
samples collected

31. Guidance on outbreak response immunization (ORI)
o Purpose: Closing immunity gap as early as possible
o Target: Unvaccinated and under vaccinated children with
MRCV more than 9 months of age
o The extent of the vaccination response will depend on the
epidemiological picture
o Ensuring vaccine availability and maintenance of buffer stock of
MRCV at GMSD, RVS, SVS etc

32. Guidance for small outbreaks
o For sporadic cases and small outbreaks of fewer than 20
cases in geographically limited or low-risk areas: (Decision
by DIO in consultation with SEPIO)
 Selective immunization of all unvaccinated and under-
vaccinated children from 9 mon – 5 yrs of age in the
immediate area of the outbreak (involved and
surrounding villages).
 Older children may need to be immunized as well,
depending on the local disease epidemiology.
 Reinforce strengthening of routine immunization services

33. Guidance on Large Outbreaks
o For larger outbreaks, or when the risk assessment indicates
there are large areas are at risk (Decision by DIO & SEPIO in
consultation with MOHFW)
 consider conducting an immunization intensification
activity that non- selectively targets larger areas.
 The target age group should be determined by disease
epidemiology and population immunity profiles.
o Response time: conduct ORI within 2 weeks of reporting as
confirmed outbreak.

34. Guidance on continued sample collection during prolonged outbreaks
 Guidance on continued sample collection during prolonged outbreaks
o If an outbreak continues over two months period, collect additional 5–
10 samples every two months to ensure that the outbreak is still due
to measles or rubella.
o If the outbreak spreads, additional samples should be collected from
the new area to confirm the outbreak is measles or rubella. Focus
should also be on collecting virology samples from outbreaks, and
genotyping.

35. Summary
• Progress in four strategic pillars key towards achieving MR elimination
• Higher MRCV coverage needed to achieve the target
- Efforts needed to sustain the gains through campaigns & IMI etc
• Quality MR surveillance; change in definition of suspected case yield results.
- Sensitivity yet to reach global standards
• Focus on ORI activity among Lab confirmed MR outbreaks
• Subsequent sensitization of FLHWs, Supervisors & Block staff for Lab.
confirmed MR cases / outbreak
• Block / District officers to track the progress in weekly meetings (DWR) on all
aspect of MR surveillance
35

36. Measles moves fast and
we need to move faster!
Thank you
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