measles

1. MEASLES
Dr. Aye Lwin
Assistant Director
CEU

2. WHAT IS MEASLES?
 Highly infectious viral disease
 Genus Morbillivirus of the paramyxoviridae family
 Exclusive human pathogen
 Single stranded RNA
 Eight classes (A, B, C, D, E, F, G and H)
 23 genotypes
 No animal reservoir or vector exits

3.  Important cause of death among young children globally
 More than 95% of measles death occur in low income countries with
weak infrastructure
 Likely to occur in
• poorly nourished children esp. not received sufficient Vitamin A
• Live in crowded conditions
• Immune deficient patients ( HIV/AIDS or others)

4. MYANMAR SITUATION
 Case based measles surveillance started in 2007 in Myanmar
 In line with regional goal, Myanmar has set goal of measles
elimination and rubella and CRS control by 2020
 Indigenous measles transmission was not found in the country
since 2013
 Genotypes detected in 2016 – H1 and D8

5. TRANSMISSION
 Contact with nose and throat secretions of infected people
 Airborne droplets released when infected person sneezes or
cough
 Can infect others for several days before and after onset of
symptoms

6. CLINICAL PRESENTATION
 Average exposure to onset of rash is 14 days
 Range 7-18 days
 Infectious from 4 days before and after onset of rashes

7. SIGNS AND SYMPTOMS
 High fever (peaking at 39-40˚C) (1st sign) 10-12 days after
exposure to measles virus and last several days
 Runny nose
 Cough
 Red and watery eye
 Small white spot (Koplik spots) in the oral mucosa, which are
pathognomonic of measles

9. SIGNS AND SYMPTOMS (CONT:)
 Raised rash
 Maculo-papular in nature
 7-18 days after exposure
 First appear on face and upper neck
then body, hand and feet
 fading after bout 3 days
 Patient normally improve by the third
day of rash
 Fully recovered 7-10 days from the
onset of disease

10. COMPLICATIONS
 Dehydration due to severe diarrhea
 In developing countries, persistent diarrhea with protein-losing
enteropathy may ensure
 Bleeding from skin and mucosa among children less than 5
years of age
 Malnutrition
 Inflammation of middle ear (5-15%)

11. COMPLICATIONS (CONT:)
 Pneumonia (5-10%)
 Encephalitis ( one in 1000 cases)
 Major causes of blindness among children in Africa and other
endemic area
 Death (5-15%)

12. SPECIMENS FOR SEROLOGY
 While IgM ELISA tests for measles and rubella are more
sensitive between days 4 and 28 after the onset of rash
 A single serum sample obtained at the first contact with the
health care system at any time within 28 days after onset is
considered adequate for surveillance purposes.
 In outbreaks where 5-10 samples have been collected,
individual diagnosis is not critical

13. NASOPHARYNGEAL SPECIMENS FOR MEASLES VIRUS
ISOLATION
Nasopharyngeal/oropharyngeal swabs
obtained by firmly rubbing the
nasopharyngeal passage and back of the
throat with sterile cotton swabs to
dislodge epithelial cells. The swabs are
placed in sterile viral transport medium in
labeled screw-capped tubes

14. VIRAL ISOLATION (CONT:)
 Samples
 Nasopharyngeal swab
 Urine simple
 Virological culture should be collected within 5 days of rash
onset
 This provide very important information about geographic
origin of measles virus importations and complements
information obtained from epidemiologic investigation
 When vaccine related cases are investigated, sequencing of a
viral isolate allows discriminating between vaccine and wild
types strains

15. TREATMENT
 No specific antiviral treatment
 Antibiotics only for
 Bacterial ear infection
 Pneumonia
 Nutritional support
 Oral rehydration solution for dehydration
 Encourage to eat and drink
 Vitamin A two doses given 24 hours apart that help prevent
 Eye damage
 Blindness
 Death reduction from measles by 50%

16. PREVENTION
Immunization
 High coverage with a two doses schedule is needed to prevent
measles epidemic
 9-12 months of age – first doses
 Second doses at least 1 month after 1st dose
 For infant at high risk – minimum age of 6 months
 Dosage- 0.5 ml
 AN thigh or upper arm
 Subcutaneous
 Storage 2-8˚C
 Keep away from sunlight

17. Surveillance

18. MEASLES SURVEILLANCE IN MYANMAR
Measles Elimination goals
 The absence of endemic measles transmission in a
geographic area (eg. Region or country) for more than 12
months in the presence of well performing surveillance
system
 It also notes that verification of measles takes place after
36 months of interrupted endemic measles virus
transmission

19. Endemic measles virus transmission
 The existence of continuous transmission indigenous or
imported measles virus that persists for more than 12
months in any defined geographic area
Endemic measles case
 Laboratory or epidemiologically linked confirmed cases of
measles resulting from endemic transmission of measles
virus

20. CASE DEFINITION FOR MEASLES SURVEILLANCE
Suspected Measles
 A patient in whom a health care worker suspects measles
infection or
 A patient with fever and maculo-papular (non-vesicular)
rash
Laboratory confirmed Measles
 A suspect case of Measles, that has been confirmed by a
proficient laboratory

21. CASE DEFINITION FOR MEASLES SURVEILLANCE
(CONT:)
Epidemiologically linked confirmed case of Measles
 A suspected case of Measles, that has not been confirmed by
a laboratory but was geographically and temporally related,
with dates of rash onset occurring 7-21 days apart to a
laboratory confirmed case, or
 In the event of a chain of transmission to another
epidemiologically confirmed measles case

22. CASE DEFINITION FOR MEASLES SURVEILLANCE
(CONT:)
Clinically compatible measles case
A case with fever and maculo-papaular (non-vesicular) rash
and one of
• Cough
• Coryza or
• Conjunctivitis
for which no adequate clinical specimen was taken and which
has not been linked epidemiologically to a laboratory
confirmed case of measles or laboratory confirmed
communicable diseases

23. Measles
Meningococcemia
Rubella
Roseola infantum
Other viral exanthema
Rash + Fever
Toxoplasmosis
Mononucleosis
Dengue
Kawasaki
Scarlet fever

24. Measles Surveillance – Summary of Case Classification
Clinically suspect
measles case
Adequate Blood
Specimen*
IgM Positive for
Rubella
Equivocal
IgM negative for
Measles & Rubella
Repeat blood test with
fresh sample and
classify as above
Lab confirmed measles
Still equivocal
Clinically
confirmed measles
Lab confirmed rubella
Discard
Clinically confirmed
measles
Epidemiologically
confirmed measles
Epidemiologically
confirmed rubella
No Adequate
Blood specimen
AND
*A single serum sample obtained at the first contact with the health care system within 28 days after onset is considered adequate for measles surveillance
Epidemiologic Link to lab
confirmed measles case or
outbreak
Epidemiologic Link to lab
confirmed Rubella case or
outbreak
No Epidemiologic link to
lab confirmed case or
outbreak
IgM Positive for
measles

25. Measles Surveillance 2017- Classification
Clinically
Confirmed
Measles
Lab
Confirmed
Measles
EPID
Confirmed
Measles
Lab
Confirmed
Rubella
Discarded Pending
cases 63 1028 186 3 347 33 1660
0
200
400
600
800
1000
1200
1400
1600
1800
no.ofcases
Data as of 16.1.2018

26. Age Group Distribution of Reported Fever with Rash cases
2017
306, 18%
399, 24%
186, 11%
74, 5%
695, 42%
0-11 months
1-4 Years
5-9 years
10-14 years
≥ 15 years
Data as of 16.1.2018

27. Immunization status of reported fever with rash cases
2017
993
162
106
9
6
320
0 200 400 600 800 1000 1200
0 dose
1 dose
2 doses
3 doses
4 doses
unknown
Data as of 16.1.2018

28. Reported Fever with Rash cases 2017 by State and Region
(n=1660) as of 16.1.2018
AYEYARWADY 156
Bago 124
Chin 3
Kachin 9
Kayah 7
Kayin 14
Magway 49
Mandalay 68
Mon State 82
Naypyitaw 30
Rakhine 99
Sagaing 7
Shan (North) 56
Shan (South) 14
Tanintharyi 61
Yangon 850
Kokant 31

29. Classification of cases with IgM positive result and
recent history of measles vaccination
Final classification Vaccination history Epidemiological findings
Discarded History of measles
vaccination within six
weeks before onset of rash
Active case search in
community does not reveal
evident of measles
infection
Confirmed History of measles
vaccination within six
weeks before onset of rash
Active case search in
community reveal other
laboratory confirmed
measles infection

30. Measles vaccine associated illness
A suspect measles case can be classified as discarded and diagnosed as
vaccine related if it meets all 5 of the following criteria
1. The patient had a rash illness, with or without fever, but did not
have cough or other respiratory symptoms related to the rash
2. The rash began 7-14 days after vaccination with a measles
containing vaccine
3. The blood specimen, which was positive for measles IgM, was
collected 8-56 days after vaccination
4. Thorough field investigation did not identified any secondary
cases
5. Field and laboratory investigations failed to identified other
causes
– Alternatively, a suspected case from which virus was isolated
and found on genotyping to be a vaccine strain will be
diagnosed as vaccine related measles

31. Measles Surveillance Performance Indicators
No Indicator Target
1 Disease incidence
Annual incidence of confirmed measles cases
Absence of indigenous
measles transmission
2 Adequacy of investigation
Proportion of all suspected measles and rubella
cases that have had an adequate investigation
initiated within 48 hours of notification
>80%
3 Outbreak investigation
Percentage of suspected measles outbreak fully
investigated
>80%
Percentage of suspected measles outbreak tested
for virus detection
>80%

32. Measles Surveillance Performance Indicators (Cont:)
No Indicator Target
4 Immunization coverage
MCV1 & MCV2 coverage nationally and by district
administrative
95% national
95% district
5 • Timeliness of reporting
• Proportion of surveillance units reporting to
the national level on time
• >80%
• >80%
6 Reporting rate of discarded non-measles, non-
rubella per 100,000 population
2
7 Representative of reporting
Proportion of sub-national administrative units
reporting at least 2 discarded non measles/
rubella cases per 100,000 population
>80%

33. Measles Surveillance Performance Indicators (Cont:)
No Indicator Target
8 Proportion of suspected cases with adequate
specimen for measles and rubella infection and
tested in a proficient laboratory
≥80%
9 Timeliness of specimen transport
Proportion of specimen received at the
Laboratory within 5 days of collection
≥80%
10 Proportion of results reported by the laboratory
within 4 days of receiving specimen
≥80%
11 Viral detection Proportion of laboratory-
confirmed chains of transmission with sample
adequate for detection measles and rubella
virus collected and tested in an accredited
laboratory
≥80%

34. Indicators of Implementation of activities for Measles
Elimination
Major Indicator Sub Indicator Target
A. Diseases Incidence
A1. Annual Incidence of confirmed
measles cases 0
A2. Annual Incidence of confirmed
rubella cases 0
B. Adequacy of
Investigation
B1. Proportion of all suspected measles
and rubella cases that was investigated
adequately within 24 hours of notification >80%

35. Indicators of Implementation of activities for Measles
Elimination (Cont:)
Major Indicator Sub Indicator Target by 2020
C. Outbreak
Investigation
C1. Proportion of suspected
measles outbreak fully
investigated
>80%
C2. Proportion of suspected
measles outbreak tested
for virus detection
>80%

36. Indicators of Implementation of activities for Measles
Elimination(Cont:)
Major Indicator Sub Indicator Target by
2020
D. Immunization coverage
D1. MCV1 coverage >95%
D2. MCV2 coverage >95%
E. Quality of reporting
E1. Timeliness of reporting (on time) >80%
E2. Reporting rate of discarded non-
measles, non-rubella per 100,000
population
2
E3. Representativeness of administrative
units reporting E2 above
>80%

37. Indicators of Implementation of activities for Measles
Elimination(Cont:)
Major Indicator Sub Indicator Target by
2020
F. Laboratory Investigation
F1. Proportion of suspected cases
with adequate specimen for measles
and rubella tested
>80%
F2. Timeliness of specimen
transport (received within 5 days at
accredited Laboratory)
>80%
F3. Timeliness of reporting results
(within 4 days of receiving specimen)
>80%
F4. Viral detection ratio (measles
and rubella)
>80%

38. Measles Outbreak Investigation

39.  Measles outbreak Definition
Any single case of confirmed measles or rubella is considered as an
outbreak in elimination setting
 Identifying a Measles outbreak
 For operational purposes, presence of suspected measles
outbreak should be verified if two more clinically confirmed
cases of measles are identified in a village or urban, ward in a
week or one or more deaths due to clinically diagnosed measles
occurs in the same geographical area
 Active searches at the reporting sights by RSO/SDCU team
leader can provide information on the occurrence of measles in
the field
 Conversation with local health workers, traditional healers and
community leaders may also be a source of information about
an unusual increase in the occurrence of measles

40. Steps of Measles outbreak investigation
1. Identifying the measles outbreaks and assigning an outbreak
number
2. Mobilization of Rapid Response Team (RRT)
3. Orientation & planning meeting at the local level
4. Conducting Measles case search including appropriate
management of cases
5. Collection and shipment of specimens to the laboratory
6. Serological confirmation of the outbreak
7. Data analysis
8. Conversion of data to information for action
9. Outbreak Notification
10. Giving feedback
11. Initiating actions-Immunization
12. Report writing

41. An Adequately investigated measles outbreak
 Initial visit to the case within 48 hours
 house to house search of cases within one week
 Information collected on all core epidemiological data variables
 Sample collected and sent to NHL
 Urine/Nasopharyngeal samples collected from at least 5 suspected
cases

42. Managing cases and contacts to limit spread
• Limiting contact to only immediate family members who have been
vaccinated or have prior history of measles
• Avoid contact with infants or young unimmunized children in the
household
• Suspected cases should not be hospitalized unless they have
complications or another condition that require hospitalization
because of intra hospital transmission
• Patients with measles who require hospitalization, if possible, be
isolated from onset of prodromal symptoms until 5 days after onset
of rash

43. Managing cases and contacts to limit spread (Cont:)
• Contacts should be limited to out patient departments (eg. Waiting
rooms)
• Officials would identify the persons who have had contact with a
confirmed measles case and take the following action to minimize
spread
 Contact (children between 6 months 5 years ) without evident
of measles vaccination should be vaccinated immediately and
the symptoms of measles should be clarified to them
 During 2nd week after exposure, at 1st sign of possible measles
(fever, runny nose, cough or red eyes) the contact should be
instructed to stay at home (eg. prevent them from attending
school, work, large gatherings)

44. Contact Management
• Contact persons with case should be identified and followed up
Four days before and after rash onset ( for rubella)
Seven days before and five days after rash onset (for measles)
• Contacts at high risk for severe measles disease
Children aged ˂5 years and adults
Person living in crowded environments
Persons with immunosuppression
 Persons with malnutrition
Persons with vitamin A deficiency
Should be evaluate and receive appropriate preventive measures

45. Contact Management (Cont:)
• Susceptible contacts who are aged-eligible and have no
contraindications to measles and rubella containing vaccine should
be vaccinated as soon as possible
• Even if contact is already infected, vaccination within two days of
exposure may help modify the clinical course of disease or may
even prevent symptoms
• If indicated, 2nd dose should be given at least 28 days after the
receipt of first dose of the vaccine
• There is no upper age limit for immunization with measles and
rubella containing vaccines
• All close contact of a suspected measles case should be identified
and monitored closely for four weeks from the day the patient
under investigation developed rash

46. Immunization response
• Epidemiological information collected during the outbreak
investigation should be analyzed and an appropriate immunization
response should be initiated
• Vaccination within 72 hours of exposure may help to prevent the
disease and mitigate severity
• Vaccination of previously unvaccinated persons should start
immediately
• If outbreak is large and may cases are occurring in infants less than
9 months, vaccination should be decrease to 6 months
 These infants should be revaccinated when they reach 9 months
of age (at least one month interval between the doses)

47. Immunization response (Cont:)
• All health workers must be vaccinated
• Children hospitalized or attending outpatient clinic and who cannot
provide written proof of MR vaccination should be vaccinated, if not
contraindicated
• Gathering points such as school, institutes and health post may be
chosen as mass vaccination sites

48. Immunization response (Cont:)
• In addition vaccination of adolescent and young adults residing or
working in institution such as
 Military bases
 High school
 Colleges’ dormitories
 Hospitals
 Religious centers
 Factories
Should be considered based on risk assessment

49. Accessing the risk of a large outbreak with high
morbidity and mortality
 As soon as outbreak is suspected, the risk of a large outbreak with
high morbidity and mortality must be accessed
 This assessment is needed to determine what type of immunization
response is most appropriate to control the outbreak
 Evaluate the susceptibility of the population and potential for
spread
 Approximately 15% of children vaccinated at 9 months of age and
5-10% of those vaccinated at 12 months of age fail to seroconvert

50. Evaluation the susceptibility of the population and
potential for spread
Example
District - X
Population - 500,000
Births per year - 12,500
Measles vaccination coverage (routine) - 80%
Measles vaccine effectiveness - 85%
Population protected against measles - 12,500 × 0.8 × 0.85
= 8500 (68%)
Measles susceptible children - 4000 (32%)

51. As a general guide, an outbreak is likely to occur when the pool of
susceptible children reach the size of one birth cohort
Year Cumulative No.
of live births
Cumulative No. of
children against measles
Cumulative No. of children
susceptible to measles
1 12500 8500 4000
2 25000 17000 8000
3 37500 25500 12000
4 50000 34000 16000
In this example, an outbreak is likely to occur in district X after 3-4
years

52. Data Analysis
During an outbreak, data collection should be limited to obtaining
basic information from each case
 Age
 Sex
 Immunization status
 Date of last vaccination
 Symptoms
 Date of rash onset
 Outcome
Collected into an outbreak line list

53. Data Analysis (Cont:)
Case fatality ratio (CFR)
CFR =
No. of cases who died of measles
Total no. of measles cases × 100
Attack rate (AR)
AR =
𝑁𝑜.𝑜𝑓 𝑐𝑎𝑠𝑒𝑠 𝑖𝑛 𝑐ℎ𝑖𝑙𝑑𝑟𝑒𝑛 𝑎𝑔𝑒 0 𝑡𝑜 11 𝑚𝑜𝑛𝑡ℎ𝑠
𝑇𝑜𝑡𝑎𝑙 𝑛𝑜.𝑜𝑓 𝑐ℎ𝑖𝑙𝑑𝑟𝑒𝑛 𝑎𝑔𝑒 0 𝑡𝑜 11 𝑚𝑜𝑛𝑡ℎ
Vaccine efficacy (VE)
VE = (𝐴𝑅𝑈 − 𝐴𝑅𝑉) 𝐴𝑅𝑈

54. Using data for action
 Failure to get vaccine
• Failure to administer at least 1 dose of measles vaccine to all the
infants continues to be the main cause of morbidity and
mortality
• Age specific AR can help to identify reasons for a failure to
vaccination
• High risk area and groups can be identified with spot maps
 Vaccine failure
• Decrease vaccine efficacy
• Cold chain failure
• Vaccine potency problems

55. Provide adequate Feedback
• Local level (RHC?MCH or UHC in the ward) including community
leaders
• Township Public Health Officer/ District Public Health Officer
• State/ Regional Health Authority
• Central Epidemiology Unit

56. Evaluate the risk of further transmission,
morbidity and mortality
• Population characteristics such as size, density, movement and
setting
• Under 5 mortality rate
• Nutrition and Vitamin A status
• HIV prevalence in the population
• Period of the year and plans for any festivals or other social event
• Number of cases reported and comparison with data from previous
years
• Access to health services

57. Conducting appropriate vaccination activities
When the outbreak is suspected
 Selective vaccination activities
 Enhance social mobilization activities
 Inform community of suspected outbreak and provide
instructions
 Vaccinate all children (6 months to 5 years) presenting to health
facilities and immunization posts 6 months to 5 year without a
history of measles vaccination
 Revaccinate children receiving measles vaccine before 9 months
 Ensure sufficient supplies are available

58. Conducting appropriate vaccination activities (Cont:)
 Reinforce EPI
 Rapidly identify priority areas within the affected district
 Joint work on strengthening the available district immunization
work plan
 Locate health centers needing additional staff or vaccine
supplies
 Correct programme weaknesses eg. Adding extra sections

59. Conducting appropriate vaccination activities
When the outbreak is confirmed
 Continue selective vaccination activities and re-enforcing EPI
 Evaluate the susceptibility of the population and potential for
spread
 Evaluate the risk of further transmission, morbidity and mortality
 If the risk assessment indicate, there is a high risk for large measles
outbreak with potential high complications and mortality
 Evaluate the availability of sufficient capacity (Staff, Vaccine &
supply, finance & other resources) to carry out a safe and a timely
campaign
 If there is sufficient capacity, conduct Non-Selective vaccination
activities (mass campaign) targeting the population and
geographical area based on local epidemiological data and risk
assessment

60. Conducting appropriate vaccination activities (Cont:)
 Timing of intervention and target population
 Once the decision to intervene has been made, it is critical to
act quickly to minimize the number of severe measles cases and
deaths
 Target coverage
 Should be 100%
 Measles immunization in emergency situations
 Eg. Floods, earth quakes, cyclones
 Prompt measles vaccination and Vitamin A supplementation of
all children between 6 months to 5 years irrespective of their
immunization status is recommended

61. Conducting appropriate vaccination activities (Cont:)
 Ensuring effective community involvement and public awareness
 Existence of an outbreak and the benefits of measles
vaccination
 Signs and symptoms of the disease
 Encourage parents whose children have had a recent rash and
fever illness to consult a health care facility
 Instruct parents to bring their children to health care facility/
vaccine post for vaccination
 Inform locations and timings of health facility/ vaccine post

62. Report writing
Report should be written systematically including
 Introduction and background information about the area affected
 Review of measles and routine immunization
 Short review of measles outbreaks in the past
 Measles reporting and surveillance system
 Confirmation of outbreak by serology
 Data collection methodology

63. Report writing (Cont:)
 Data analysis
• Time, place and person analysis of case
• Mapping of cases
• Age distribution and vaccination status analysis
• Attack rate analysis
• Analysis of case fatality rate
• Vaccine efficacy analysis
• Proportion of vaccine preventable cases

65. Report writing (Cont:)
 Probable reasons of outbreak
 Population at risk
 Case management and Vitamin A
 Response to outbreak
 Conclusion and recommendation
 the report should also include
• Relevant charts, Maps and graphs
• Key rates and indicators
Report should be sent to township, district, province and CEU

66. In January 2017, five cases of fever with rash who were living in
Hlaingtharyar were admitted to Yangon Children Hospital.
YCH MS reported to CEU, what would you do?

67. Thank You