1. Measles and Rubella Surveillance in the time of Zika: Brazil
Sergio Nishioka
Department of Communicable Disease Surveillance,
Ministry of Health, Brazil
23 June 2016

2. Case definitions
Measles – suspected case Patient with fever plus maculopapular rash plus cough and/or coryza and/or conjunctivitis, independent of age and vaccination
Rubella – suspected case
Patient with fever plus maculopapular rash plus (retroauricular and/or occipital and/or cervical) lymphadenopaty, independent of age and vaccination
CRS – suspected case
Newborn, infant or child until 12 months of age whose mother was a suspected case of rubella or contact of a confirmed rubella case and/or who has the following clinical signs or complications: congenital cataract/glaucoma and/or cardiopathy (persistance of ductus arteriosus, pulmonary stenosis, aortic stenosis) and/or deafness

3. Case confirmation and comments
For MEASLES and RUBELLA: laboratory diagnosis, epidemiological link or clinical criteria (during outbreaks)
For CRS: laboratory diagnosis or epidemiological link
Comments
The definition for suspected measles cases has been considered easier to handle during outbreak investigations than the more sensitive definition restricted to fever and rash
In 2016, until EW18 there were 1.18 million reported suspected cases of dengue in Brazil
Large numbers of individuals with fever and rash due to dengue fever have been observed in Brazil long before the introduction of Zika
Most doctors have never seen measles cases

4. Measles and rubella cases
__________________________________________________________________
Year
Reports / cases ________________________________________
Total no. reports
Confirmed measles cases
Laboratory
Clinical
Confirmed rubella cases *
Discarded
Laboratory
Clin / epi
Clinical
Vaccine link
*Imported case from the Philippines; no secondary case

5. MR outbreak investigations - Additional info
Pernambuco outbreak (03/2013 – 03/2014)
226 cases
153,741 reviewed charts
Ceará outbreak (12/2013 – 07/2015)
1052 cases
504,829 reviewed charts
15,317 (3%) out of 487,880 dengue-neg samples tested for M&R (2012 – 2015) – all negative
940 (11%) out of 8586 chikungunya-neg samples tested for M&R (2014 – 2015) – all negative

6. Zika
SUSPECTED CASE: Patients who have pruriginous maculopapular rash plus at least TWO of the following signs and symptoms: Fever OR Non-pruriginous Conjunctival Hyperemia OR Polyarthralgia OR Periarticular swelling
CONFIRMED CASE: suspected case with one of the following positive tests for the diagnosis of Zika: Viral isolation; Detection of viral RNA RT-PCR; IgM antibodies
Case definition for Zika-associated microcephaly
In Brazil, the surveillance is on “microcephaly and/or CNS abnormalities suggestive of congenital infection in fetuses, aborted fetuses, stillborn babies and newborns”
So far only a small proportion of suspected cases have had laboratory confirmation for Zika

7. Reported Zika cases, Brazil, 2016, EW 1 to 15

8. Zika cases by age group and gender, Brazil, 2015-2016

9. Zika positive test distribution by trimester of pregnancy (until 5 May 2016)

10. Impact of Zika on MR surveillance - 1
Was MR surveillance system used as a platform for Zika surveillance? If yes, why? How was this done?
Once Zika virus was identified as the cause of the outbreak of exanthemathous illness in NE Brazil this disease was included among those under the supervision of the National Dengue Control Program, which is separated from the MR Surveillance in the MoH organigram.
Change in case definition? Investigations?
No change in the MR case definitions. The clinical manifestations of Zika are more similar to measles than dengue is. Most Zika cases would be included in the Brazilian MR case definition. However, dengue is still much more common than Zika in the country as a whole.

11. Impact of Zika on MR surveillance - 2
Laboratory testing algorithm change?
Tests for chikungunya and Zika (RT PCR) became available recently and have been added to the algorithm
Laboratory resources?
Increased demand for testing, need for training and for lab personnel

12. Negative impact on MR surveillance?
Has MR surveillance suffered?
After microcephaly cases started to be reported and became a priority the surveillance of all other communicable diseases was affected
What steps taken to address this?
MR surveillance activities have been maintained but interaction with Zika and microcephaly surveillance teams needs improvement
Was lab overwhelmed?
Yes, at regional and some reference labs before Zika was identified, for the differential diagnosis.
After the microcephaly cases, priority given to Zika has affected time to perform the tests in regional and some reference labs.

13. Zika microcephaly and CRS
Has CRS platform helped with Zika microcephaly surveillance? If yes, how was this done?
Yes, regarding the differential diagnosis of TORCH in the newborn.
However, the surveillance system adopted in Brazil goes beyond that as it includes also pregnant women, abortions and stillbirths.

14. Lessons learnt
How has Zika surveillance improved or hurt M/R/CRS surveillance?
“Microcephaly surveillance” is likely to improve CRS surveillance. The (so far) poor interaction between Zika surveillance and MR surveillance teams at country and state levels has not helped MR surveillance.
What lessons have been learnt from Zika on how to ensure strong MR surveillance during competing health priorities?
What lessons have been learnt from Zika on how to build on M/R/CRS platform in emergency situations?
Zika may be seen (so far) as a missing opportunity to improve MR surveillance
MR surveillance needs to adapt to new times
In Brazil, nowadays, it should be more integrated with the dengue / chikungunya / Zika surveillance
Educate clinicians on clinical definitions of measles and rubella (to be lab confirmed) and better interaction with primary care

15. Thank you