India EIS Seminar 1 st April 2014 Measles Outbreak Investigation in District Haridwar of State Uttarakhand, February-March 2014 Dr. Yogita Tulsian & Dr.Pankaj

India EIS Seminar1st April 2014

Measles Outbreak Investigation in District Haridwar of State Uttarakhand,

February-March 2014

Dr. Yogita Tulsian & Dr.Pankaj SinghIndia Epidemic Intelligence Officers

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India EIS Seminar 2014

Introduction[1]Disease Burden—Threat---Solution

Measles is a highly infectious systemic childhood disease affecting predominantly the respiratory system

Measles killed 7-8 million children a year and caused an estimated 135 million cases per year worldwide before the introduction of vaccination in the 1960s.

But even in 2007 there were 197 000 measles deaths globally which account for nearly 540 deaths everyday and 22 deaths every hour

Measles vaccine was introduced in to the universal immunization program (UIP) of the country in 1985

Number of cases has come down from 252,000 cases in 1987 to 36900 cases in 2007.

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Introduction[2] Reporting of Measles Outbreak

On 13th January 2014: 191 cases and no deaths were reported, Banjarewala and Amanatgadh of block Bhagwanpur, MOB UA HRD 14 001 outbreak(224 cases and no death)

On 25th January 2014: 54 cases and no death were reported,Thithola of block Narsan, MOB UA HRD 14 002

On 31st January 2014: 57 cases and no death and 46 cases and no death were reported,Puhana and Dada Jalalpur of block Imlikhera and block Bhagwanpur respectively, MOB UA HRD 14 003 and MOB UA HRD 14 004 outbreaks.

Later MOB UA HRD 14 005 and MOB UA HRD 14 006 outbreaks were named to new cases notified from area Laksar and Bahadarabad in district Haridwar in sporadic manner

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Introduction[3]Actions Taken by District team and WHO team

From initial 4 outbreaks WHO has sent 5 samples each from each outbreak for measles and rubella laboratory confirmations.

Mop up measles vaccination campaign was conducted on 27th January 2014 by WHO and district team.

We sought for a comprehensive outbreak investigation We conducted outbreak investigation from 14th February

to 14th March 2014

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Aims and Objectives

To describe the epidemiological characteristics of the outbreak

To identify risk factors associated with the outbreak To provide recommendations to prevent additional cases and

future recurrence of the outbreak

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Materials and Methods

Case definition We defined a case of measle as a person with Fever and

rash with any one of the following symptoms cough, coryza and conjunctivitis since 1st November 2013 residing in the district Haridwar of state Maharashtra.

Case ascertainment We reviewed the surveillance data and line list available,

compiled by the local officials during the investigation. We reviewed case papers and confirmed the case definition for all cases listed; local health workers information and case sheets were used to update the line list

We also searched additional cases

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Laboratory and Environmental Data Collection

District and WHO officials have sent 5 samples from each initial 4 outbreaks. In 1st outbreak 3 were positive for IgM elisa measles test out of 5 samples, In 2nd outbreak, again 3 were positive for measles out of 5 samples, In 3rd outbreak all 5 were positive for measles. In 4th outbreak sample results are waiting. Those results which were negative for measles, were tested for rubella, all tested for rubella were negative. We did not collect any new specimens during the outbreak investigation

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Study Hypothesis

• We hypothesized that the low vaccination coverage could be the reason for this measles outbreak.

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Descriptive AnalysisTime Distribution

• The epi curve shows that the outbreak was started in 2nd week of November

• Epidemic curve is showing peak in the mid of January 2014, during 11th to 18th January.

• Index case was notified on 13thJannuary 2014

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Figure: Epidemic Curve in Measles Outbreak in District Haridwar, Uttarakhand- March 2014

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Descriptive AnalysisPlace Distribution

• Maximum number of cases were in the block Bhagwanpur and in village Banjarewala

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Figure: Place Distribution in Measles Outbreak in District Haridwar, Uttarakhand- March 2014

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Descriptive AnalysisPerson Distribution

• Maximum attack rate was in the age group of 1 to 5 years

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Table: Age Specific Attack Rates in Measles Outbreak in District Haridwar, Uttarakhand- March 2014

Age specific attack rates in district Haridwar Age in Years Population Cases Attack rate/1,00,000 population <1 49446 60 121

1-5 197786 286 145 >5 1643190 180 11

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Figure : Age Specific Attack Rates in Measles Outbreak in District Haridwar, Uttarakhand- March 2014

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Table: Age and Sex Wise Attack Rates in Village Banjarewala Block Bhagwanpur in Measles Outbreak in District Haridwar,

Uttarakhand- March 2014

Male Female Total

Age in years

case

population

Attack rate (%)

case

population

Attack rate (%)

Case

Population

Attack rate (%)

<1 14 53 26 7 25 28 21 78 27

1-4 56 144 39 61 151 40 117 295 40

5-9 34 208 16 38 144 26 72 352 20

10-14 3 284 1 3 341 0.9 6 625 1.0

>15 1 1038 0.09 2 1083 0.2 3 2121 0.14

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Figure : Age and sex wise attack rate in village Banjarewala of block Bhagwanpur in measles outbreak in district

Haridwar, Uttarakhand- March 2014

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Case control study

To examine our hypothesis and to evaluate potential risk factors for measles, we conducted a case-control study

Case: We defined a case of measle as a person with Fever and rash with any one of the following symptoms cough, coryza and conjunctivitis since 1st November 2013 residing in the district Haridwar of state Maharashtra.

Control: A control was defined as a person residing in the district Haridwar and who did not have fever and rash since 1st November 2013.

Cases and controls were matched by sex, village and age (age match: +/- 1 years for all below 5 years and +/- 5 year for all cases above 5 years).

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Sample size - Data collection - Data analysis

95% confidence interval, 80% power, 40% exposure in the cases, 20% in controls, and calculated by epi info case control calculation formula. It was 83 cases and 83 controls and 15% extra for non response cases.

A questionnaire was prepared to collect data on socio demographic details, clinical data, travel history, and potential exposures. The questionnaire was administered in the households of the cases and controls, in the local language.

We analyzed data using EPI info and SPSS

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Ethical Considerations

• This was a public health response to an outbreak and as such did not require ethical review. We protected the confidentiality of participants through use of codes and did not enter personal identifiers into the study database

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Results:1

Cases enrolled in the case control study were in the age group of 1-4 years (38/83; 46%) and 5-9 years age group (38/83; 46%); remaining cases were from above 10 years age (7/83; 8%)

Clinical presentation of cases was with fever and rash and also cough in 86% cases (71/83), coryza in 88% cases (73/83) and conjunctivitis in 83% of cases (69/83).

Cases enrolled were 47% male (39/83) and 53% female (44/83)

Socioeconomic characteristics were statistically not significant.

Also history of visit to neighboring village or to any function in last 3 months also not significant

Indicator Cases Controls Odds Ratio CI P valueEducation of child School going

57 55 1.11 0.19-2.35 0.76

Mother educationIlliteracy

75 75 1 0.34-2.9 0.79

Mother occupationWorking

03 05 0.5 0.11-2.62 0.71

Father Working

80 82 0.32 0.01-3.13 0.61

House CharacteristicsKaccha house

26 24 1.12 0.57-2.19 0.86

ReligionMuslim

26 24 1.12 0.57-2.19 0.86

Economic levelLow

72 77 0.51 0.16-1.45 0.30

Economic levelMedian

10 06 1.75 0.60-5.43 0.43

Economic levelHigh

01 00 NA

Visit to neighbor village

13 08 1.73 0.67-4.65 0.35

Visit any function 05 07 0.69 0.19-2.35 0.76

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Results:2

Measles complication was in 12% (10/83) of cases, out of this conjunctivitis was common complication (5/10; 50%), pneumonia was in (3/10; 30%) and diarrhea was in (2/10; 20%) cases

Treatment taken by measles cases was in nearby government/ private center. 38.55% (23/83) measles cases has taken treatment, 72 %( 60/83) measles cases waited for self remittance and did not visited to any health center for any treatment.

Immunization card was available with 26.5% (22/83) cases, whereas with 38.5% (32/83) controls the immunization card was available.

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Results:3 Vaccination Results

Vaccination status in cases, for vaccine BCG (50/83; 60.24%), DPT-OPV1 (46/83; 55.42%), DTP-OPV2 (40/83; 48.19%). Whereas in controls the vaccination status was better, for vaccine BCG (60/83; 72.28%), DPT-OPV1 (60/83; 72.28%), DTP-OPV2 (40/83; 69.87%).

Number of cases vaccinated for DPT-OPV3 (32/83; 38.55%), in controls for DPT-OPV3 (57/83; 68.67%), which was statistically significant (p<0.05).

Measles vaccination in cases was 18.07 %( 15/83) and in controls it was 65 %( 54/83), which was statistically significant (p<0.05).

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Table : Vaccination history in measles outbreak case control study in district Haridwar, Uttarakhand- March 2014

Vaccination history Cases Controls Odds Ratio CI P value

BCG 50 60 0.58 0.3-1.11 0.13

DPT1 46 60 0.47 0.2-0.9 0.03

OPV1 46 60 0.47 0.2-0.9 0.03

DPT2 40 58 0.4 0.2-0.7 0.007

OPV2 40 58 0.4 0.2-0.7 0.007

DTP3 32 57 0.28 0.15-0.54 0.0001

OPV3 32 57 0.28 0.15-0.54 0.0001

Measles 1 15 54 0.12 0.05-0.24 0.0000001

Measles 2 00 00

Vitamin 1 15 54 0.12 0.05-0.24 0.0000001

Vitamin 2 00 00

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Results:4 Reasons

Reasons for low vaccination was mainly no immunization sessions held during those period was statistically significant (OD: 7.5; P :< 0.05)

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Table: Reasons for low vaccination in measles outbreak case control study in district Haridwar, Uttarakhand- March

2014

Reasons for no vaccination

Cases Controls Odds Ratio CI P value

No immunization sessions

66 28 7.5 3.77-15.49 <0.05

Refusal 02 01 2 0.15-60 0.62

Distance from house

00 00

Travel conveniences issue

00 00

Health staff attitude

00 00

Family barrier 02 01 2 0.15-60 0.62

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Conclusions

Measles outbreak was due to low immunization coverage, specially measles vaccine and vitamin A doses in the affected area

The 70% posts of ANMs in Haridwar district were vacant in the affected area since past 2-3 years and those posts were filled up ( 30%) were on strike for few months during those years, so additional immunization sessions were not held in sufficient numbers in the affected area

This year only WHO has initiated measles surveillance and they detected measles outbreak, it may be possible the same measles outbreak in the past years also in the affected areas

• The purpose of the study, procedures of study enrolment, risks and benefits of enrolment, and potential uses of data were explained in detail to every eligible subject.

• Only patients who provided written informed consent were included in the study.

• To ensure confidentiality and anonymity of the participants, personal identifiers (name and address) were removed from the files, and unique identifier was given

• Study was approved by ethical committee.

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Recommendations

ANMs post must be kept filled up either by permanent staff ( as per availability and guidelines) or by temporary staff

In place of ANMs vacant post, regular alternative additional immunization sessions must be held in the vacant post area

Measles notification and surveillance system must be strengthened and even suspect cases to be notified to the health authorities.

Documents

India EIS Seminar 1 st April 2014 Measles Outbreak Investigation in District Haridwar of State Uttarakhand, February-March 2014 Dr. Yogita Tulsian & Dr.Pankaj