MEASLES BULLETIN World Health Organization, Western Pacific Regional Office, Manila, Philippines Issue 9 June 2006
World Health Organization Regional Office for the Western Pacific Expanded Programme on Immunization
ISSN 1814 3601
Measles outbreak in Fiji, February-May 2006
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rior to February 2006, Fiji was regarded as having interrupted transmission of indigenous measles virus. From 2002 to 2004 Fiji reported 304, 305 and 35 measles cases, respectively, although no confirmatory laboratory testing was conducted but rubella was confirmed in the Pacific during those three years. The last previous documented outbreak of confirmed measles in Fiji was in late 1997 and early 1998, with a total of 955 cases reported. A national measles campaign was held in 1997. It targeted children nine months to 14 years old with reported coverage of 85%. However, the actual number of children targeted was uncertain and the estimated coverage may have been as low as 58%. In 2001, a measles campaign was held targeting children nine months to five years old with reported coverage of 86%. Routine measles vaccine coverage averaged 83% from 2001 to 2004. A scheduled second dose of measles vaccination in the form of measles-rubella (MR) vaccine was introduced in 2003 as a school entry requirement. However, the second-dose coverage has never been reported. In 2005 it was discussed at the annual Pacific Immunization Programme Strengthening meeting that Fiji could expect a measles outbreak in 2006 given the increasing number of children susceptible to measles infection resulting from less than optimal measles vaccination coverage rates.
In mid-February 2006, three cases of measles were confirmed by serologic testing for the presence of anti measles immunoglobulin M (IgM) antibody at the national laboratory in Fiji and at the WHO Measles Regional Reference Laboratory in Australia. The three cases were from the western side of the main island. The Ministry of Health reported that one of the cases developed symptoms while on an island frequently visited by tourists. This case is most likely imported as the genotype perfectly matches the Shanghai/Taiwan H1 genotype. Following confirmation, measles surveillance was enhanced in Fiji by us-
gion. Simultaneously, measles surveillance from the 19 sites in the Pacific region were increased from monthly to weekly reporting and posted on the Pacific Public Health Surveillance Network. The Ministry of Health promoted isolation of children with AFR by developing and disseminating triaging guidelines for all health facilities. Providing vitamin A to measles cases in health facilities was difficult because vitamin A is not part of the National Drug Formulary and was not available in hospitals or health centres. To ensure adequate and appropriate immunization response to the measles outbreak, the Ministry of Health formed a task force that included various departments (e.g. clinic and hospital paediatric care, Fiji Pharmaceutical Services and Center for Health Promotion). The task force also included representatives of the United Nations Children's Fund, the Japan International Cooperation Agency, the Australian Agency for International Development, the Fiji Health Sector Improvement Program, the New Zealand Agency for International Development, the Secretariat of the Pacific Community, the United States Centers for Disease Control and Prevention and WHO, who provided technical and financial support. To improve population immunity, the continued on page 2
ing the case definition (acute fever and rash, or AFR) and cough, coryza, or conjunctivitis with daily telephonic active surveillance of 21 hospitals throughout the country. Daily feedback on the course of the outbreak was disseminated widely within Fiji. On 2 March a notice was sent to the Pacific Public Health Surveillance Network to alert the re-
MEASLES BULLETIN Ministry of Health task force recommended that children entering primary school in 2006 immediately be provided MR vaccine rather than a gradual implementation throughout the school year. The western division, where the outbreak started, was the first division to implement this recommendation; other divisions followed. In addition, the task force planned a nationwide immunization campaign targeting approximately 100 000 children, six months to six years of age. The vaccinated schoolchildren were not identified as part of the national campaign and were not included in the denominator of children targeted. In spite of the limited time to prepare and coordinate the microplanning, social mobilization, training, monitoring and logistics management, Fiji implemented the campaign over a period of four weeks beginning 3 April. Most areas were completed within four weeks; the more challenging areas took up to six weeks. A post campaign rapid coverage assessment was undertaken to identify and vaccinate children not vaccinated during the campaign. Most parents who failed to vaccinate their children during the campaign stated they were "too busy" to take their child to a health facility. The asFigure 1: Number of confirmed cases 8 7 6 Number of cases 5 4 3 2 1 0 01 Feb 06 Feb 11 Feb 16 Feb 21 Feb 26 Feb 03 M ar 08 M ar 13 M ar 18 M ar 23 M ar 28 M ar 02 A pr 07 Apr 12 A pr 17 A pr 22 A pr 27 A pr 02 M ay 07 M ay 12 M ay 17 M ay 22 M ay
D a te o f o n s e t o f ra s h
sessment process identified another weakness in the health programme; there was not a systematic method to follow up non-compliant children and communities. Among an estimated target population of 91 600 children, age six months to six years, 89 750 (98%) received MR vaccine during the campaign. As of 2 June 2006, the Ministry of Health of Fiji reported a total of 132 measles cases (see Figure 1); 117 were from the western division and 13 from the central/eastern division. Over 60% were children from the target age group, with the highest incidence occurring in the nine- to 11-month age group (4.1 per 1000). Pneumonia was the most serious
outcome and no deaths were reported. The current status of Fiji in terms of measles elimination is defined by the WHO Weekly Epidemiological Record1 and the Field Guidelines for Measles Elimination as a stage of "sustained measles transmission" as long as cases continue to be reported and confirmed. Endemicity will be re-established if transmission continues uninterrupted for six months or more.
Monitoring the interruption of indigenous measles transmission, Cape Town meeting, 14 October 2003. Weekly Epidemiological Record, 2004, 7:70-72 1
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MEASLES BULLETIN WHO Western Pacific Region Measles Laboratory Network Update - Accreditation To attain measles elimination in the Region, a highly sensitive surveillance system needs to be established to detect measles cases without delay and omission in reporting and to help identify transmission pathways by providing the initiative with genetic information of measles virus. As remarkable success has been achieved in controlling measles, and as the elimination phase is close at hand, laboratory diagnosis of suspected cases becomes more critical. It is estimated that clinical diagnosis of laboratories (RRL) in Melbourne, Australia and Beijing, China are already fully accredited in their category, the WHO regional measles laboratory network has been striving to extend the necessary groundwork and procedures allowing full assessment of the accreditation status of the national level measles laboratories (NML). Accreditation of NMLs are reviewed annually by the WHO Regional Office based on laboratory performance during the immediately preceding 12 m o n t h s . Accreditation is given for the forthcoming year, if findings prove that the laboratory successfully satisfies the six criteria for accreditation as shown below: 1. Test results are reported by the laboratory on at least 80% of measles IgM samples within seven days of receipt. Should the country concerned require a shorter turnaround time for its NML, this would override the seven-day requisite. 2. Serological tests are performed on at least 50 serological specimens annually. To maintain skills in performing serological assays, virus laboratories should maintain appropriate reagents and assay kits to have capacity to test continually through the year. Any ELISA assays similar to the one for measles IgM detection can be counted for this requirement. 3. The accuracy of measles and 3
rubella IgM detection is at least 90%. Accuracy is determined by the agreement in test results on sera submitted by the NML to the RRL during the 12-month review period. The percentage of samples sent for validation is dependant on the quality of the laboratory and could range from 10% to 100%. Samples for validation should be representative of all results (positive, negative and equivocal) and outbreaks, and should be sent to the RRL at regular intervals, preferably twice a year. 4. Internal quality control procedures for IgM assays are implemented. Appropriate quality control procedures are in place and followed. 5. The score on the most recent WHO approved proficiency test is at least 90%. Proficiency test results to be reported within 10 days of panel receipt to receive full credit. 6. The score from the annual on-site review of laboratory operating procedures and practices is at least 80%. All the national and regional reference laboratories participating in the proficiency test programme have passed for two distinct sets of the panel for 2004 and 2005 with excellent scores. Some of the laboratories have already undergone an initial on-site review and have shown their competency to external reviewers. Confirmatory testing also has been arranged for each laboratory within the network so as to complete the full assessment of the accreditation of the laboratories for the first time. It is expected that full accreditation status will be conferred to certain laboratories shortly and that this milestone will be reached by all the remaining laboratories in due course.
acute measles virus infection may have a positive predictive value of barely 5% in this later stage. The WHO measles laboratory network in the Region maintains strong progress. A hands-on measles laboratory workshop, held in March in Hong Kong (China), largely focused on conventional ELISA assay and measles virus isolation in a bid to reinvigorate capacity-building and strengthening the service of the designated national measles laboratories. In addition to providing training, the network has set a WHO accreditation scheme in an effort to ensure and monitor quality of its services as agreed in its inaugurating meeting in 2004. While the regional reference
MEASLES BULLETIN Pacific Immunization Programme Strengthening Workshop May 2006 The UNICEF/WHO Pacific Immunization Programme Strengthening Workshop was held in Fiji from 8 to 12 May 2006 and was attended by Ministry of Health representatives from 16 Pacific island countries and areas, and by regional and international experts in the field of immunization. The meeting helped to place immunizations in the forefront of health services delivery in the Pacific, as the Ministry of Health representatives reiterated their commitment to the regional twin goals of measles elimination and hepatitis B control by 2012. The twin goals challenge all Pacific countries and areas to ensure that their health services reach every newborn and provide lifesaving vaccines and other health interventions within their first year of their life. The group engaged in discussions and sought solutions to common issues, such as the continuous exodus of health staff that has hampered the delivery of health services and immunizations in particular. The meeting also featured current issues such as the recent importation of the measles virus into Fiji, which has served as a reminder of the continued threat posed by infectious diseases such as measles and polio, and the important protection that vaccines can provide children in the Pacific. The group also engaged in expert discussion on fully understanding congenital rubella syndrome in the Pacific. A parallel session of the Subregional Committee for the Certification of Poliomyelitis Eradication in the Pacific island countries and areas enabled several joint sessions and discussions among the two groups. The second annual workshop was co-organized by the Australian Agency for International Development, the Japan International Cooperation Agency, the New Zealand Agency for International Development, the Secretariat of the Pacific Community, the United States Centers for Disease Control and Prevention, the United Nations Children's Fund and WHO.
International Finance Facility for Immunization The International Finance Facility for Immunization (IFFIm) is a new international development financing institution that is supported by several donor countries - Brazil, France, Italy, Norway, Spain, Sweden and the United Kingdom. The central aim of IFFIm is to save more children’s lives and to do so quickly. By investing the majority of resources up front—“frontloading”—this innovative funding programme will increase significantly the flow of aid to ensure reliable and predictable funding flows for immunization programmes and health systems development until 2015. An anticipated IFFIm investment of US$ 4 billion is expected to prevent five million child deaths between 2005 and 2015, and more than five million future adult deaths. IFFIm has recently agreed to fund the “Measles Investment Case” proposed by the Global Alliance for Vaccines and Immunization (GAVI). As part of this initiative, GAVI will contribute US$ 37 million to the United Nations Foundation for support of measles supplementary immunization activities/catch-up campaigns. This will trigger a US$ 9.25 million matching grant from the United Nations Foundation. The WHO Regional Office for the Western Pacific submitted a proposal to fund primarily measles SIA activities, and to a lesser degree measles surveillance activities and activities supporting strengthening of routine EPI. The proposal identifies the four largest GAVI eligible countries in the Region (Cambodia, the Lao People’s Democratic Republic, Papua New Guinea and Viet Nam) and would cover the period of 2006-2007. If funded, the support provided by this project grant would significantly boost the efforts of these countries in meeting the measles elimination goal of 2012. 4
MEASLES BULLETIN Table 1. Regional Measles Monitoring of Country Surveillance Data (January-December 2005)* Classification Φ Incidence rate (Total confirmed) 2004 2005 Indicators Suspected cases Ω immunized Latest date reported by Type of report Deaths country Reported Confirmed cases suspected cases Laboratory Epi-linked Clinical confirmed
Discarded Pending
Australia Brunei Darussalam Cambodia China Hong Kong (China) Japan X
11 264 83
11 3
†
0 0 1 73 0 0 1 0 0 0 241
0 143 16 209 0 1,067 0 16 118 1 0 137
0.23 (45) 2.55 (352) 0.73 (51) 6.84 (8,752) 25.74 (1,491) 0.00 (0) 23 (5,729) 0.00 (0) 0.83 (33) 24 (1,385) 3.7 (3,025) 0.02 (11) 2.25 (96) 0.26 (217)
0.06 (11) 1.06 (146) 0.93 (65) 0.43 (546) 4.99 (289) 0.00 (0) 4.68 (1,187) 0.00 (0) 0.50 (20) 0.14 (118) 0.01 (7) 0.77 (33) 0.68 (574)
0 118 18 6 5 891 4 0 92 56 0 12845
0 0 0 0 0 0 0 0 0 0 0 605
36% (4) 45% (120) 16% (13) 33% (96) 80% (4) 75% (3) 20% (4) 40% (80) 67% (42) 57% (7,971)
0 0 0 0 0 0 0 0 1 0 0 0
24-Jan-06 26-Jan-06 26-Jan-06 14-Oct-05 11-Jan-06 09-Jan-06 02-Jun-06 25-Dec-05 17-Jan-06 26-May-06 28-Mar-06 05-Jun-06 09-Jan-06 02-Jun-06
case data case data case data aggregate aggregate case data aggregate case data case data aggregate case data case data case data case data
48 7 0 120 0 3 0 6 33 196
546 Lao People's Democratic Republic 295 Macao (China) 5 Malaysia Mongolia New Zealand Papua New Guinea Philippines Singapore Viet Nam Pacific Island Countries: American Samoa Cook Islands Fiji French Polynesia Guam Kiribati Marshall Islands Micronesia, Federated States of Nauru New Caledonia Niue Northern Mariana Islands Palau Samoa Solomon Islands Tokelau Tonga Tuvalu Vanuatu Wallis and Futuna Western Pacific Region 19039 0 0 0 0 0 0 X
2,078 4 20 1,403 210 63 33 14024
Republic of Korea
0
0
0
0.00 (0)
0.00 (0)
-
-
-
0
07-Apr-05 zero-reporting
0 0 0 0
0 0 0 0
0 0 0 0
0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0)
0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0)
0 0 0 0
0 0 0 0
-
0 0 0 0
07-Jul-05 zero-reporting 07-Sep-05 zero-reporting 05-Sep-05 zero-reporting 02-Aug-05 zero-reporting
0
0
0
0.00 (0)
0.00 (0)
0
0
-
0
06-Sep-05 zero-reporting
427
316
1707
14035
605
1
* Data are based on country reports and other sources available to EPI/Western Pacific Regional Office. Φ Incidence rate per 100 000 population (population figures from World Population Prospects: The 2004 Revision, New York, United Nations, 2005). Ω Suspected cases immunized does not distinguish between 1 or 2 doses. † Lab confirmed or epidemiologically linked to a laboratory confirmed case X Sentinel surveillance system
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MEASLES BULLETIN Table 2. Regional Measles Monitoring of Country Surveillance Data (January-June 2006)* Classification Φ Incidence rate (Total confirmed) 2005 2006 Indicators Suspected cases immunizedΩ Latest date reported by Type of report Deaths country Reported Confirmed cases suspected cases Laboratory Epi-linked Clinical confirmed
Discarded Pending
Australia Brunei Darussalam Cambodia China Hong Kong (China) Japan Lao People's Democratic Republic Macao (China) Malaysia Mongolia New Zealand Papua New Guinea PhilippinesX Republic of Korea Singapore Viet Nam Pacific Island Countries: American Samoa Cook Islands Fiji French Polynesia Guam Kiribati Marshall Islands Micronesia, Federated States of Nauru New Caledonia Niue Northern Mariana Islands Palau Samoa Solomon Islands Tokelau Tonga Tuvalu Vanuatu Wallis and Futuna Western Pacific Region X
97 110 38 22 2 383 9 7
97† 0 15 0 1 33 0 0
0 0 0 0 0 0 0 1
0 74 14 18 0 91 0 3
0.04 (8) 0.30 (43) 0.55 (39) 4.56 (258) 0.00 (0) 3.60 (879) 0.00 (0) 0.18 (7)
0.48 (97) 0.52 (74) 0.41 (29) 0.30 (18) 0.22 (1) 0.48 (124) 0.00 (0) 0.10 (4)
34 9 0 1 259 9 0
2 0 4 0 0 0 3
14% (14) 36% (40) 39% (15) 18% (4) 50% (1) 89% (8) 0% (0)
0 0 0 0 0 0 0 0
02-Jun-06 26-May-06 30-May-06 05-Jun-06 05-Jun-06 09-Jun-06 23-May-06 26-May-06
case data case data case data aggregate case data aggregate case data case data
65 16 1029
21 16 75
0 0 44
0 0 0
0.00 (0) 0.42 (18) 0.02 (19)
0.04 (21) 0.37 (16) 0.14 (119)
37 756
7 154
52% (34) 59% (611)
0 0 0
05-Jun-06 25-May-06 02-Jun-06
case data case data case data
0 132 1 0 0 2 1 0 0 0 0 0 0 0 0 0 1914 Φ
0 22 0 0 0 0 0 0 0 0 0 0 0 0 0 0 280
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 45
0 110 0 0 0 0 0 0 0 0 0 0 0 0 0 0 310
0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) -
0.00 (0) 15.57 (132) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0)
0 1 0 0 2 1 0 0 0 0 0 0 0 0 0 1109
170
6% (8) -
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
15-May-06 zero-reporting 02-Jun-06 15-May-06 case data aggregate
15-May-06 zero-reporting 15-May-06 zero-reporting 15-May-06 15-May-06 aggregate aggregate
15-May-06 zero-reporting 15-May-06 zero-reporting 15-May-06 zero-reporting 15-May-06 zero-reporting 15-May-06 zero-reporting 15-May-06 zero-reporting 15-May-06 zero-reporting 15-May-06 zero-reporting 15-May-06 zero-reporting
* Data are based on country reports and other sources available to EPI/Western Pacific Regional Office. Incidence rate per 100 000 population (population figures from World Population Prospects: The 2004 Revision, New York, United Nations, 2005). Ω Suspected cases immunized does not distinguish between 1 or 2 doses. † Lab confirmed or epidemiologically linked to a laboratory confirmed case X Sentinel surveillance system
Comments may be sent to Dr Ernest Smith smithe@wpro.who.int or Ms Margaret Hercules herculesm@wpro.who.int Please send quarterly data to Mr Dexter Bersonda at bersondad@wpro.who.int WORLD HEALTH ORGANIZATION, Regional Office for the Western Pacific, United Nations Avenue, P.O. Box 2932, 1000 Manila, Philippines Fax No. (632) 5211036, 5260279, 5260362 Tel. No. (632) 5288001 6