Surveillance of Surveillance of Measles and TetanusMeasles and Tetanus

Surveillance of Surveillance of Measles and TetanusMeasles and Tetanus

Dr Pushpa Raj SharmaDr Pushpa Raj Sharma

Professor of Child HealthProfessor of Child Health

Overview

Measles, global view and control strategies

Epidemiology,clinical presentation and vaccine

Measles surveillance

Outbreak investigation

In 1998 it is estimated that there were approximately one million deaths from

measles

MORTALITY

PRE-VACCINE ERA

1998

MORBIDITY

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1

2

3

4

5

6

7

Mill

ions

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20

40

60

80

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120

Millions

PRE-VACCINE ERA1998

WHO unpublished data

63% 83%

In other words,

the measles virus killed …..

2,410 children each day

100 children each hour

…. 150 children died during the time elapsed by the end of this presentation

Diphtheria0.2%

Pertussis16%

Neonatal Tetanus

12%

Yellow Fever2%

Measles48%

(777,000 Deaths)

Hib22%

Causes of 1.6 million vaccine-preventable deaths among children, 2000

Source: WHO/IP

MEASLES: A leading cause of childhood deaths

There are three WHO Regions with established measles elimination goals: the Pan American region, 2000, the European region, 2007 and the

Eastern Mediterranean region 2010. The other regions: Africa, South East Asia and the Western Pacific have goals to control

measles transmission.

2000

2007

2010

Block-area outbreak prevention/elimination goal

1983 1985 1987 1989 1991 1993 1995 1997

Year

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Cases

Coverage

*Reported to WHO Headquarters, as of August 8, 1999

The number of reported global measles cases has reduced and measles vaccine coverage has increased from 1983-1998

Improved RoutineImproved RoutineImmunizationImmunization

StrengthenStrengthenmeasles surveillancemeasles surveillance

SupplementalSupplementalmeasles immunizationmeasles immunization

Improved caseImproved casemanagementmanagement

Vitamin AVitamin Asupplementationsupplementation

Measles Mortality Reduction Strategies

No 2nd opportunity (40 countries or 19%)Yes 2nd opportunity (174 countries or 81%)

Countries providing second opportunitysecond opportunity for

measles immunization, 2002

Since 1999, additional 12 countries

National Immunization Program of Nepal

National Policy:

Immunization is

- the national priority program of His Majesty’s Government of Nepal.

- immunization ranks third among 20 prioritized interventions

Goal of the Immunization Program:

•Reduce morbidity and mortality associated with Vaccine Preventable Diseases and thus contribute reduction of :

-infant Mortality from 64.4/1000 live births, to 50/1000 and- under five mortality from 91.2/1000 live birth to 70/1000 by the year 2003.

Objective:

• Reduce global measles-related mortality by half by 2005.

WHO/UNICEF Global Strategic Plan 2001-2005

Surveillance Goals

• Identify cases / outbreaks;

by date and geographical area

• Age distribution and vaccination status of cases and deaths

• Identify high risk populations/areas

• Investigation and verification of outbreaks

• Maintain timeliness and completeness

• Provide feedback

Maculopapular Rash

Fever +

Cough ORCoryza (runny nose) OR Conjunctivitis (red eyes)

+

Suspected Measles Clinical Case Definition

ORClinician Suspects Measles

Measles Case Definition To Assist Communities in

Notifying Health Facilities

ANY PERSON

with

FEVER and RASH

Key Information to Collect on Suspected Measles Cases

PersonAgeVaccination statusLab data

TimeDate of rash onset

PlaceResidence at onsetPotential exposures (places, persons)

What should health care provider do when she/he

suspects measles?• Notify case

• Complete case investigation form

• Collect blood sample

• Manage case (Vitamin A, supportive tx, etc.)

High risk areas: How to identify them?

Most susceptibles

Status of measlesStatus of measlesvaccination coveragevaccination coverage

Most affected groups

Analysis of measlesAnalysis of measlessurveillance datasurveillance data

Transmission is facilitated

Socio-demographicSocio-demographiccharacteristics of populationcharacteristics of population

High risk area is where:

there is a significant number of susceptibles

disease remains endemic conditions facilitate contact between

susceptible and infectious individualsconditions facilitate chances of

“effective” transmissiongreater risk of severe measles and

higher CFR

Rash IllnessRubella

Roseola Infantum

Other Viral Exanthems

Meningococcemia

Mononucleosis

Toxoplasmosis

Dengue

Kawasaki

Measles

Scarlet Fever

Measles Vaccine

• Live virus vaccine

• Freeze dried (lyophilized) and used with diluent

• Store vaccine at 2°-8° C (but can be frozen)

• Protect from light at all times

• Efficacy:

• 85% at 9m (EPI schedule) • 95% at 12-15m

• Duration of immunity: life long

Outbreak Response

1. Case notification

2. Case verification

3. Field investigation

4. Management

5. Post outbreak activities

What is an outbreak?

“Number of cases observed in a given geographical area is greater than that normally expected in the area during a given period of time”

• Increase over “usual number” of cases• Problem – we don’t know usual number!• Look for clustering of cases by time/place• Arbitrary guideline – 5 or more cases in

one week at one site

Steps in Outbreak Response

• Step 1: Pre-outbreak planning & preparation

• Step 2: Detection, notification, & verification

• Step 3: Pre-investigation planning

• Step 4: Field investigation

• Step 5: Post-outbreak activities

Detection, notification, and verification

Upon suspecting or being notified of a possible outbreak, following information should be collected:

– Number of suspected cases & number hospitalized

– Population at risk (school, rural village, urban area, non-Nepali-speaking, etc.)

– Location of outbreak and accessibility of the location

Notification

• SMO: Notify PEN Main office and DHO/DPHO

• PEN Main Office: notify EDCD

• SMO: Verify outbreak, if possible

Case Management

Vitamin A supplementationRespiratory isolation of hospitalized

casesSupportive treatment (antipyretics,

antibiotics, fluids)Treatment of complications as needed

Measles Treatment with Vitamin A

AGE Immediately on Diagnosis

Next Day

0-6 months 50,000 IU 50,000 IU

6-11 months 100,000 IU 100,000 IU

> 12 months 200,000 IU 200,000 IU

* For ocular manifestations, give a 3rd dose 2-4 weeks after the 2nd dose

Measles: Key Messages

• Leading cause of mortality in developing world• Safe effective vaccine is available• High routine coverage and second opportunity

needed to stop measles transmission • Effective surveillance needed to direct control

strategies• Investigation should include blood collection

and contact tracing (in future?)• All suspected measles cases should be

reported

Neonatal tetanus

A silent killer disease

Presentation OverviewPresentation Overview

Global overview and strategies of MNTE

Surveillance Epidemiology and clinical presentation

Prevention and vaccinationChallenges ahead

2000 - 238,000 cases*2000 - 238,000 cases*Countries with MNT eliminated: 104Countries with MNT eliminated: 104

1990 - 561,000 cases*1990 - 561,000 cases*Countries with MNT eliminated: 76Countries with MNT eliminated: 76

SOUTH EAST ASIA64,000 deaths

What is neonatal tetanus elimination?

“The reduction of neonatal tetanus cases to fewer than 1 case per 1,000 live births in every district of every country”

WHO and UNICEF target:

Elimination by 2005!

NT incidence < 1 / 1000 live births in every district

High Routine & High Routine & supplementary supplementary ImmunizationImmunization

• All pregnant mothersAll pregnant mothers

• WCBAWCBA

Clean deliveries and cord Clean deliveries and cord practicepractice

Effective NT surveillanceEffective NT surveillance

• health facility basedhealth facility based

• community community involvementinvolvement

To sustain elimination

• Increase routine TT coverage for pregnant women

• Increase routine DPT coverage for children

• Increase women’s access to and use of clean delivery services

Countries with SIAs in High Risk Areas, Countries with SIAs in High Risk Areas, as as

of December 2001of December 2001

MNT eliminated or potentially eliminated (106)

MNT not eliminated, no SIAs initiated (34)

MNT not eliminated, SIAs initiated (21)

Standard Case Definition

Confirmed Neonatal TetanusAny neonate with a normal ability to suck and cry during the first 2 days of life, and between 3 and 28 days of age cannot suck normally, and becomes stiff and/or has convulsions

Suspect Neonatal TetanusAny neonatal death between 3 and 28 days of age in which the cause of death is unknown; or any neonate reported as having suffered from NT between 3 and 28 days and not investigated

Reasons for Under-Reporting

• Awareness

(Many deaths occur at home without ever presenting to the medical system)

• Difficulties in disease diagnosis (in peripheral health facilities)

• Newly introduced program

(where to report)

NT Cannot Be Eradicated

• Widely prevalent in environment

• Does not require human-to-human contact for transmission or survival

• Only VPD that is infectious, but not contagious

• Can only be eliminated (1 case/1000 live births in given district)

Tetanus Clinical Features• Incubation period 8 days (range, 3-21 days)

• Three clinical forms: Local (uncommon), cephalic (rare), generalized (most common)

• Generalized tetanus: descending symptoms of Masseters-trismus (lockjaw), difficulty swallowing, muscle rigidity, spasms, Facail muscle-risus sardonicus, Muscle of back and neck-opisthotonus

• Spasms continue for 3-4 weeks; complete recovery may take months

Differential Diagnosis

• Bacterial meningitis

• Encephalitis

• Severe mouth or dental may simulate

trismus

• Rabies

• Strychnine poisoning

Management

•Isolation

•Wound debridement

•Toxin neutralization: TIG 500 U IM (3000-6000)

Or TAT 50,000-100,000 U IM

•Antibiotic

•Sedative

•Supportive

Recommended Schedule – DPT(for infants)

•DPT1 – 6 weeks

•DPT2 – 10 weeks

•DPT3 – 14 weeks

•Injected IM in the outer part of the thigh

•Dose – 0.5ml

•Given together with OPV

Challenges AheadChallenges Ahead

• Balancing priorities in immunization– polio NIDs, measles, MNT, introduction of new

vaccines & improving routine

• Achieving elimination:– Ensuring 80% coverage of TT SIAs in each high risk

district targeted

• Maintaining elimination:– Identifying innovative strategies and funding to routinely

achieve 80% TT2+ and DPT3/measles in every district

– Appropriate strategies for school immunization programmes

% of pregnant women immunized with TT2

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20002001

Source:MIS

Thank you!Thank you!