Presented By: Dr.Preetam Kumar Kar

Facilitators: Dr.Dipanweeta RoutrayDr.Manoj Kumar Dash

Department of COMMUNITY MEDICINES.C.B MEDICAL COLLEGE AND HOSPITAL

CUTTACK.

LAYOUT OF PRESENTATION

Introduction

Background

Vision & Goals of Global Measles elimination Strategic Plan 2012

Guiding Principles to Eliminate Measles

Strategy to Eliminate Measles

Initiatives in India

Challenges in Implementing the Strategic Plan

Conclusion

Bibliography

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3

Background of measles Elimination

4

GLOBAL SCENARIO

Measles is endemic virtually in all parts of the world.

In 2000: 5.35 lakh children died of measles, themajority in developing countries (WHO report).

Burden accounted for 5% of all under- five mortality.

Epidemics occur when proportion of susceptible childrenreaches about 40 percent.

5

GLOBAL SCENARIO

All 35 countries in the Americas eliminated measles in 2002.

The Western Pacific Region

European and

Eastern Mediterranean

African

SE Asian countries

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reduced measles cases between 2009 and 2012 and is now on the verge of measles elimination.

focusses on measles control i.e reduction of measles morbidity and mortality in accordance with the target.

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Number of estimated measles deaths (in thousands) globally

2000-2010

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Source: who global measles & rubella strategic plan 11

535.3 528.8 484.3373.8 331.4 227.7384.8

177.9

139.3

137.5130.1

INDIAN SCENARIO

In India 2011- 33,634 cases with 56 deaths.

Leading cause of child deaths.

The national routine measles vaccination coverage is 69% (DLHS-3).

Draft Comprehensive Multi Year Strategic Plan (2010-17) for immunisation of India the country with an objective of reducing measles related mortality by 90% by 2013 compared to 2000.

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MEASLES AS AN ELIMINABLE DISEASE

1. Humans are the only reservoir for measles virus.

2. Accurate diagnostic tests for measles.

3. Effective interventions.

4. Life long immunity.

5. Sustained interruption of measles virus transmission.

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12

VISION

Achieve and maintain a world without measles .

GOALS

A. By end 2015 Reduce global measles mortality by at least 95%

compared with 2000 estimates. Achieve regional measles elimination goals.

B. By end 2020 Achieve measles elimination in atleast five WHO regions.

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Regional Measles & Rubella Elimination Goals

WHO world map of regional goals for the elimination of measles and either the elimination or control of rubella

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WHO defines elimination of measles as absence of

endemic measles for a period of >=12 months in

presence of adequate surveillance.

One indicator of measles elimination is a sustained

measles incidence of <1/10 lakh population.

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DEFINITION

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1. COUNTRY OWNERSHIP AND

SUSTAINABILITY

National governments and civil society to work

together.

2. ROUTINE IMMUNIZATION AND HEALTH

SYSTEMS STRENGTHENING

Robust and effective health and immunization

systems, particularly a strong national EPI.

3. EQUITY

Specifically target children missed by routine services,

including underserved, migrant and poor children.17

4. LINKAGES

With polio eradication:

Providing polio vaccination during measles SIAs , facilitate

both polio eradication & measles control & elimination.

With other proven child survival interventions:

The routine measles vaccination visit at nine months

is widely used to provide vitamin A supplementation.

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19

The strategy for 2012–2020 builds on the experiences in the Americas and in countries in other WHO regions that successfully eliminated indigenous transmission of measles.

High coverage with two doses of MCV serves as the foundation required to ensure high population immunity against measles.

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Component 1. ACHIEVE AND MAINTAIN HIGH LEVELS OF

POPULATION IMMUNITY

Vaccination Coverage >=95% with each of the two doses

of MCV.

Unvaccinated children old enough to receive MCV1 (9 or

12 months).

Strengthening routine immunization - critical component.

Catch up and follow up.

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Component 2.

MONITOR DISEASE USING EFFECTIVE SURVEILLANCE

AND EVALUATE TO ENSURE PROGRESS

Effective surveillance needed to provide information :

1. To set priorities

2. Plan activities

3. Allocate resources

4. Implement prevention programmes

5. Respond to outbreaks

6. Evaluate control measures

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Component 3.DEVELOP AND MAINTAIN OUTBREAK

PREPAREDNESS AND RESPOND RAPIDLY TO

OUTBREAKS

In elimination setting :

Single case outbreak rapid investigation

and response.

In emergency setting:

Urgent coordinated SIAs include

Vit. A supplementation prevent outbreaks and

child mortality.

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Component 4.COMMUNICATE AND ENGAGE TO BUILD

PUBLIC CONFIDENCE

Community awareness regarding

a. Immunization rights

b. Benefits

c. Safety

d. Available services

Will promote public acceptance and participation.

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Component 5.PERFORM RESEARCH AND DEVELOPMENT

CDC in May 2011 highlighted critical research areas

necessary to achieve measles eradication:

1. Measles epidemiology

2. Assessing vaccine efficacy and effectiveness

3. Needle free vaccine delivery methods

4. Improved methods for laboratory testing for

measles

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5. New immunization strategies.

6. Improved methods to monitor and evaluate vaccination

programmes.

7. Improved messages and strategies to communicate with

potential beneficiaries and their families.

8. Economic analyses of different strategic options and

mathematical modeling.

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Component 5.PERFORM RESEARCH AND DEVELOPMENT….contd

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ACCELERATED MEASLES CONTROL

STRATEGIES

1. Improve and sustain RI coverage (MCV-1).

2. Provide a second opportunity for measles immunization to all

eligible children (MCV-2).

3. Sensitive, laboratory supported measles outbreak surveillance

for case/outbreak confirmation.

4. Fully investigate all detected measles outbreaks and ensure

appropriate case management.

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LEGEND

2012

2011

Dhenkanal

Ganjam

Jajpur

Kalahandi

Khurda

Koraput

Malkangiri

Nabarangpur

Nayagarh

Rayagada

Bargarh

BolangirBoudh

Sonepur

Sambalpur

Angul

Balasore

Bhadrak

Deogarh

Jharsuguda

Keonjhar

Mayurbhanj

Sundargarh

Jagatsingpur

Kendrapara

Puri

Cuttack

Gajapati

ANDHRA

PRADESH

JHARKHAND

N

Reported Measles Outbreaks in the years

2011, 12 & 13

Kandhamal

2011, 2012 & 2013

201329Source: SMO , NPSP unit Ganjam

CASE OF CLINICAL MEASLES

Any person in whom clinician suspects measles infection

OR

Any person with fever and maculo papular rash with Cough / Coryza / CONJUNCTIVITIS

OR

A death which occurs within one month of onset of measles

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For epidemiological investigation, clinical measles would be a case within last 3 months.

CONFIRMATION OF OUTBREAK

By Serology

Positive Measles IgM antibody in any of the 5 blood samples collected during the outbreak and tested in a WHO accredited Laboratory.

(Measles negative samples are tested for Rubella)

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Desk Review of Measles data every Tuesday at district level

Identify blocks with 5 cases or 1 death in a week

WHICH POTENTIAL OUTBREAKS TO INVESTIGATE?

Any death in a block5 cases in a block

IF YESConduct preliminary field search in area to look for additional cases

Assess if these cases are clustered in same/ adjacent villages

IF ADDITIONAL CASES FOUND (~10 CASES)conduct detailed investigation: HTH search, Serology from 5 cases,

Rx for all cases (Vit A, ORT etc.) 32

PLANNING FOR MEASLES OUTBREAK

INVESTIGATIONSERT

Members: CMO. District Surveillance Officer RCH Officer / DIO Epidemiologist Pediatrician / physician Laboratory Specialist Statistical Officer Surveillance Medical Officer (SMO) others from the district as appropriate (partner

representatives)

The local MO to be co-opted at the time of the outbreak investigation.

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2. ASSIGNING OUTBREAK NUMBER & PRELIMINARY

SEARCH

Assigning an Outbreak Number

MOB-ST-DIS-YY-NUM

MOB-0R-GJM-14-001

The PHC MO should ensure that the village/ locality of the area is searched for additional cases.

The outcome of the search should be communicated to the RCH Officer.

The RCH Officer/ SMO/IDSP-SO should decide if the outbreak needs to be investigated in detail.

The state should be notified using the VPD-OB001 form

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3. MOBILIZATION OF THE EPIDEMIC RESPONSE

TEAM

When: As soon as an outbreak is identified.

Why: For detailed outbreak investigation at the outbreak locality.

Who: The CMO of the district convenes a meeting of all members of the ERT.

For: Micro planning the outbreak Investigation.

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Form VPD-OB003

Village / Area: ________________ PHC:_________________ Block:__________________________ District:__________________________ State:___________________

Outbreak ID: _________________________________ Report sent by:_____________________Date Sent: ____________

Sex

Date of last

measles

vaccine

Date of onset

of rash

If died, date of

death

Date of blood

specimen

collection

M/F Years Months dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy

Unknown Unknown

Unknown Unknown

Unknown Unknown

Yes

No

Yes Yes

No No

Yes

Setting: Urban / Rural

No

Age

Yes Yes

No No

Patient's name, father's name

and address

Patient

number

Received

measles

vaccine

(circle)

MEASLES OUTBREAK INVESTIGATION: DATA ON CASES

Death

(circle)

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Steps contd…..

Children suffering from Measles should be given

First dose of Vit A by health worker and informed of second dose.

Supervisor to follow up with second dose

of Vit A.

Manage the existing cases.

Ask the family to report occurrence of new Measles cases to the local health worker/nearest health center immediately.

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6-7. COLLECTION AND SHIPMENT OF SPECIMENS

TO THE LABORATORY

SPECIMEN COLLECTION & PROCESSING

Co

lle

ct s

eru

m i

n

lab

ele

d s

teri

le v

ials

Cen

trif

uge

Clo

tted

Blo

od

Leave at Room Temp for clot formation (30 mins.)

Centrifuge @ 1500 RPM – 10 Min

Storage

8. DATA ANALYSIS

Defining the outbreak in terms of time, place & person

Age distribution

Proportion of cases vaccinated in different age groups (How is RI performance?)

CFR

Mapping of cases: particular areas or communities of village affected.

Calculation of attack rates and vaccine efficacy if community survey done.

9. REPORT WRITING AND FEEDBACK

Share the experience with programme implementers (form VPD – OB004).

Document for comparison in the future Learning for an evolving programme.

To be sent to state government, IDSP, GoI and NPSP.

Form VPD-OB004

Outbreak ID: _______________________

Notification

Source of notification: Weekly report / Active case search / Media / Other

Index case reported by:______________ Name of DIO:________________________

Designation:____________________ Name of SMO:_______________________

Date of notification of index case: ______________

MEASLES OUTBREAK INVESTIGATION: SUMMARY

Desk review: date________________________ findings________________________________________________________

Date/s of preliminary search:__________________________

Number of health facilities searched: ___________________ Number of sub-centers/ urban wards searched: _________

Number of areas* searched:__________________ Total number of clinical measles cases:__________

Date of Epidemic Response Team meeting: ____________________

Whether considered as an outbreak requiring house to house investigation: Yes / No

If No, reason: No clustering of cases Low case count

Others (specify ) ________________________________________________________________

If Yes, provide details of outbreak investigation below

Preliminary investigation including desk review

10. INITIATING ACTIONS

State level action

Collect data to guide development of policy.

Taking next step in measles control.

District Level action

Prevent death – Vit-A, ORT. Antibiotics, Referral chain.

Ensure availability of vaccines.

Improve routine immunization.

Targeting populations at risk.

Local level actions

Ensuring vaccine is available in all sessions.

Ensure that sessions are not missed.

Ensure coverage is complete in the target population.

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1. FINANCIAL RISKS

Sufficient predictable and sustainable funds .

2. HIGH POPULATION DENSITY AND HIGHLY

MOBILE POPULATIONS

The highly infectious nature of measles makes

control and elimination very challenging.

3. CONFLICT AND EMERGENCY SETTINGS

Humanitarian crises

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3. WEAK IMMUNIZATION SYSTEMS AND

INACCURATE REPORTING OF VACCINATION

COVERAGE

High infectiousness & high rate of clinical disease.

Strengthening routine immunization systems.

4. MANAGING PERCEPTIONS AND

MISPERCEPTIONS

When individuals no longer see cases of a

previously common disease they begin to believe

the vaccine no longer provides benefits.

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CONCLUSION

Improving measles vaccination coverage and reducing measles-related deaths is a global imperative, particularly as it relates to the United Nation’s Millennium Development Goal 4 (MDG4), which aims to reduce the overall number of deaths among children by two-thirds between 1990 and 2015.

We must work together to increase and sustain the socio-political and financial commitments required to end the devastation associated with preventable measles.

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TAKE HOME MESSAGEReverse the resurgence of measles,achieve the 2015 mortality-reduction target& look beyond, to reap the tremendouslong-term humanitarian and economic benefits associated with a world free of measles.

BIBLIOGRAPHY

1.Levels & trends in child mortality report 2011: Estimates developed by the UN Inter-agency Group for Child Mortality Estimation. New York, NY, United Nations Children’s Fund, 2011 (http://www.childinfo.org/files/Child_Mortality_Report_2011.pdf, accessed 11 March 2012).

2. Wolfson LJ et al. Estimates of measles case fatality ratios: a comprehensive review of community-based studies. International Journal of Epidemiology, 2009, 38:192–205.

3. WHO/UNICEF Global Plan for reducing measles mortality 2006–2010 (http://whqlibdoc.who. int/hq/2005/WHO_IVB_05_11_eng.pdf).

4. Strebel PM et al. A world without measles. Journal of Infectious Diseases, 2011, 203:S1–S3.

5.Park’s textbook of Preventive and Social Medicine 22nd edition.

6.Health Policies and programmes in India.dr. D.K.Taneja..

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