Measles - Epidemiology and Control

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Measles

Dr. Rizwan S A, M.D.,

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Outline

• 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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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.

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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.

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Outline


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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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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)

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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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• 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--16.3. CDC. Global measles mortality, 2000--2008. MMWR 2009;58:1321--6.

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• 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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• Laboratory-confirmed measles and rubella outbreaks in states conducting measles outbreak surveillance — India, 2010

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Outline


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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

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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

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 buccal mucosa.)

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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

• 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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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 inter-epidemic interval.

• This period of low incidence following widespread immunisation is called ‘honeymoon period’

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• 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 low-incidence period, though remaining lower than the pre-immunization 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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• 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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• 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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• 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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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

• 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

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 cost-effectiveness. 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

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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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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 two-thirds 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%)

MCV1 & regular SIAs (59 member states or 31%)

MCV1, MCV2 & one-time catch-up (36 member states or 19%)

MCV1, MCV2 & regular SIAs (57 member states or 28%)

Single dose (1 member state or 1%)

Data source: WHO/IVB measles database as of 26 January 2010

India national immunization programmeintroduced

second dose of measles in 2010

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Key Strategies for Measles Mortality Reduction

1. High coverage of measles 1st dose2. Sensitive laboratory supported surveillance3. Case management including vitamin A supplementation4. 2nd opportunity for vaccination

There are 2 ways of providing 2nd opportunity they area. Routine 2nd dose of measlesb. 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.

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

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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, Jharkhand, M.P, Manipur, Meghalaya, Nagaland, Rajasthan, Tripura 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

RI: MCV1 >80%: 21 states

SIA: MCV1 <80%: 14 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• 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 Inter-

personal 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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CHANDIGARH

D&N HAVELI

LAKSHADWEEP

DELHI

JAMMU & KASHMIR

HIMACHAL PRADESH

PUNJAB

HARYANA

JHARKHAND

SIKKIM

MANIPUR

MEGHALAYA

MIZORAMGUJARAT

CHHATTISGARH

ORISSA

ANDHRA PRADESH

GOA

PONDICHERRY

DAMAN & DIU

A&N ISLANDS

UTTARAKHAND

BIHARASSAM

TRIPURAWEST BENGAL

KARNATAKA

TAMIL NADU

KERALA

MAHARASHTRA

RAJASTHANUTTAR PRADESH

NAGALAND

ARUNACHAL PR.

MADHYA PRADESH

CHANDIGARH

D&N HAVELI

LAKSHADWEEP

DELHI

JAMMU & KASHMIR

HIMACHAL PRADESH

PUNJAB

HARYANA

JHARKHAND

SIKKIM

MANIPUR

MEGHALAYA

MIZORAMGUJARAT

CHHATTISGARH

ORISSA

ANDHRA PRADESH

GOA

PONDICHERRY

DAMAN & DIU

A&N ISLANDS

UTTARAKHAND

BIHARASSAM

TRIPURAWEST BENGAL

KARNATAKA

TAMIL NADU

KERALA

MAHARASHTRA


NAGALAND

ARUNACHAL PR.

MADHYA PRADESH

CHANDIGARH

D&N HAVELI

LAKSHADWEEP

DELHI

JAMMU & KASHMIR

HIMACHAL PRADESH

PUNJAB

HARYANA

JHARKHAND

SIKKIM

MANIPUR

MEGHALAYA

MIZORAMGUJARAT

CHHATTISGARH

ORISSA

ANDHRA PRADESH

GOA

PONDICHERRY

DAMAN & DIU

A&N ISLANDS

UTTARAKHAND

BIHARASSAM

TRIPURAWEST BENGAL

KARNATAKA

TAMIL NADU

KERALA

MAHARASHTRA


NAGALAND

ARUNACHAL PR.

MADHYA PRADESH

Phase 1 in 2010 -11; Phase 2 in 2011-12; Phase 3 in 2012-13 Starting Sep 12

Phase 2, 152 districts covered (~ 40 million)

Phase 1, 45 districts covered (~ 13 million)

Phase 3, 167 districts planned (~ 81 million)

Overview of Measles SIA

Target population: ~ 135 million children 9

months – 10 years of age 365 districts in 14 states

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State Total number of Districts

Districts covered in Phase 1

Districts covered in Phase 2

Number of Districts for

Phase 3

ARUNACHAL PR. 16 1 15

ASSAM 26 1 25

BIHAR 38 5 15 18

CHHATTISGARH 18 9 9

GUJARAT 32 5 5 22

HARYANA 21 5 16

JHARKHAND 24 5 19

MADHYA PRADESH 50 5 13 32

MANIPUR 9 1 8

MEGHALAYA 7 1 6

NAGALAND 11 1 10

RAJASTHAN 33 5 5 23

TRIPURA 4 1 3

UTTAR PRADESH 75 3 72

Total 364 45 152 167

Target Population ~134,000,000 13,845,686 40,167,580 ~81,000,000

Coverage (% Achieved)

12,076,836 (87.2%)

36,102,564 (89.9%)

Measles SIA phasing plan, India

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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 Childrenmonitored 2465 22438

287758 31462 49174

132343

140880

181299 160 3308 2175 41846 3280 27867

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Campaign awareness & source of information (in %)

94.9

83.7

16.4

7.7 5.31.4

0

10

20

30

40

50

60

70

80

90

100

Awarness for thecampaign

Health worker/ASHA/AWW

Teachers Family members/Community

Newspaper/Poster/ Banner

TV/Radio/Miking

• 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%

N= 638,660 children monitored

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Reasons for missing vaccination during Measles catch-up campaigns-India (RCA)

4%

44%

52%

Social mobilisation

Operational

Others

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

(N – 87,197)

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All State Governments have issued orders to include Measles 2nd dose under RI in

campaign districts after 6 months

Measles SIA timeline (3rd phase)

MADHYA PRADESH GUJARAT RAJASTHAN BIHAR UTTAR

PRADESHPeriod of campaign No. of Districts

Sep-12 12 (17 Sep) 22 (13 Sep) 9 (17 Sep) Oct-12 7 Nov-12 8 18 Dec-12 5 8 22Jan-13 6 Feb -13 16Mar -13 11Apr-13 23

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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

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Impact on measles transmission

[Data as on August 2012]

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State

MCUP Phase & (No. of districts

covered)

Pre-MCUP Surveillance data from MCUP districts* MCUP

activity completed

by

MM-YYYY

Post-MCUP Surveillance data from MCUP districts #

Reference period (From)

MM-YYYY

Total number

confirmed measles

outbreaks

Total number of confirmed measles

cases

Reference period (until)

MM-YYYY


outbreaks


cases

Assam 1 (1) NA NA 12-2010 12-2011 0 0

2 (26) 07-2011 7 353 06-2012 08-2012 0 0

Bihar 1 (5) NA NA 01-2011 01-2012 0 0

2 (15) 06-2011 2 82 02-2012 08-2012 0 0

Gujarat 1 (5) 07-2010 14 546 07-2011 07-2012 0 0

2 (5) 03-2011 1 15 03-2012 08-2012 0 0

Jharkhand 1 (5) NA NA 03-2011 03-2012 0 0

2 (19) 07-2011 7 238 03-2012 08-2012 0 0

Madhya Pradesh

1 (5) 07-2010 5 354 01-2011 01-2012 0 0

2 (13) 01-2011 8 492 01-2012 08-2012 0 0

Rajasthan 1 (5) 12-2009 4 211 12-2010 12-2011 2 54

2 (5) 03-2011 3 60 03-2012 08-2012 0 0

Grand Total

1 ( 26) 23 1111 2 54

2 (83) 28 1240 0 0

Data as on 13/08/2012

Measles cases and outbreaks in districts completed catch-up campaigns and lab supported measles surveillance before and after start of MCUP

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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

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Outline


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NPSP assisted measles surveillance

Each state supported by a WHO-accredited lab

Year surveillance initiated

2006

2007

2009

2010

2011

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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

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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

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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

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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

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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

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Triggers for investigation outbreak

• >= 5 clinical cases in a block in a weekOr

• >= 1 death due to measles in a block in a weekOr

• >= 5 clinical cases in an area bordering several blocks

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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

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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

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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

95The National Polio Surveillance Project - India

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)

96The National Polio Surveillance Project - India

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

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

2005 2006 2007 2008 2009 2010

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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

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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 5-9 yr 10-14 yr >= 15 yr

Vaccinated Not Vaccinated Unknown

*Cases from serologically confirmed measles outbreaks

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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

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IDSP – measles

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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

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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

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Outline

• Terminology• History• Burden• The disease• Epidemiology• The vaccine• Measles control in India• Surveillance• Measles and MDG 4• Feasibility of eradication

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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

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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%

107

Outline


108

Feasibility of global eradication

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Global goals

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

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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

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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)

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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

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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

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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, Follow-

Up 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

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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

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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

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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

118

Thank you

Measles - Epidemiology and Control

Health & Medicine

Transcript of Measles - Epidemiology and Control