1. India EIS Seminar 1 st April 2014 Measles Outbreak Investigation in District Haridwar of State Uttarakhand, February-March 2014 Dr. Yogita Tulsian & Dr.Pankaj Singh India Epidemic Intelligence Officers

2. 2 India EIS Seminar 2014 Introduction[1] Disease Burden—Threat---Solution  Measles is a highly infectious systemic childhood disease affecting predominantly the respiratory system  Measles killed 7-8 million children a year and caused an estimated 135 million cases per year worldwide before the introduction of vaccination in the 1960s.  But even in 2007 there were 197 000 measles deaths globally which account for nearly 540 deaths everyday and 22 deaths every hour  Measles vaccine was introduced in to the universal immunization program (UIP) of the country in 1985  Number of cases has come down from 252,000 cases in 1987 to 36900 cases in 2007.

3. 3 India EIS Seminar 2014 Introduction[2] Reporting of Measles Outbreak  On 13 th January 2014: 191 cases and no deaths were reported, Banjarewala and Amanatgadh of block Bhagwanpur, MOB UA HRD 14 001 outbreak(224 cases and no death)  On 25 th January 2014: 54 cases and no death were reported,Thithola of block Narsan, MOB UA HRD 14 002  On 31 st January 2014: 57 cases and no death and 46 cases and no death were reported,Puhana and Dada Jalalpur of block Imlikhera and block Bhagwanpur respectively, MOB UA HRD 14 003 and MOB UA HRD 14 004 outbreaks.  Later MOB UA HRD 14 005 and MOB UA HRD 14 006 outbreaks were named to new cases notified from area Laksar and Bahadarabad in district Haridwar in sporadic manner

4. 4 India EIS Seminar 2014 Introduction[3] Actions Taken by District team and WHO team  From initial 4 outbreaks WHO has sent 5 samples each from each outbreak for measles and rubella laboratory confirmations.  Mop up measles vaccination campaign was conducted on 27 th January 2014 by WHO and district team.  We sought for a comprehensive outbreak investigation  We conducted outbreak investigation from 14 th February to 14 th March 2014

5. 5 India EIS Seminar 2014 Aims and Objectives  To describe the epidemiological characteristics of the outbreak  To identify risk factors associated with the outbreak  To provide recommendations to prevent additional cases and future recurrence of the outbreak

6. 6 India EIS Seminar 2014 Materials and Methods  Case definition  We defined a case of measle as a person with Fever and rash with any one of the following symptoms cough, coryza and conjunctivitis since 1 st November 2013 residing in the district Haridwar of state Maharashtra.  Case ascertainment  We reviewed the surveillance data and line list available, compiled by the local officials during the investigation. We reviewed case papers and confirmed the case definition for all cases listed; local health workers information and case sheets were used to update the line list  We also searched additional cases

7. 7 India EIS Seminar 2014 Laboratory and Environmental Data Collection  District and WHO officials have sent 5 samples from each initial 4 outbreaks.  In 1 st outbreak 3 were positive for IgM elisa measles test out of 5 samples,  In 2 nd outbreak, again 3 were positive for measles out of 5 samples,  In 3 rd outbreak all 5 were positive for measles.  In 4 th outbreak sample results are waiting.  Those results which were negative for measles, were tested for rubella, all tested for rubella were negative.  We did not collect any new specimens during the outbreak investigation

8. 8 India EIS Seminar 2014 Study Hypothesis We hypothesized that the low vaccination coverage could be the reason for this measles outbreak.

9. 9 India EIS Seminar 2014 Descriptive Analysis Time Distribution The epi curve shows that the outbreak was started in 2 nd week of November Epidemic curve is showing peak in the mid of January 2014, during 11 th to 18 th January. Index case was notified on 13thJannuary 2014

10. 10 India EIS Seminar 2014 Figure: Epidemic Curve in Measles Outbreak in District Haridwar, Uttarakhand- March 2014

11. 11 India EIS Seminar 2014 Descriptive Analysis Place Distribution Maximum number of cases were in the block Bhagwanpur and in village Banjarewala

12. 12 India EIS Seminar 2014 Figure: Place Distribution in Measles Outbreak in District Haridwar, Uttarakhand- March 2014

13. 13 India EIS Seminar 2014 Descriptive Analysis Person Distribution Maximum attack rate was in the age group of 1 to 5 years

14. 14 India EIS Seminar 2014 Table: Age Specific Attack Rates in Measles Outbreak in District Haridwar, Uttarakhand- March 2014

15. 15 India EIS Seminar 2014 Figure : Age Specific Attack Rates in Measles Outbreak in District Haridwar, Uttarakhand- March 2014

16. 16 India EIS Seminar 2014 Table: Age and Sex Wise Attack Rates in Village Banjarewala Block Bhagwanpur in Measles Outbreak in District Haridwar, Uttarakhand- March 2014 MaleFemaleTotal Age in years cas e populat ion Attack rate (%) ca se populat ion Attack rate (%) Ca se Populat ion Attack rate (%) <114532672528217827 1-45614439611514011729540 5-9342081638144267235220 10-143284133410.966251.0 >15110380.09210830.2321210.14

17. 17 India EIS Seminar 2014 Figure : Age and sex wise attack rate in village Banjarewala of block Bhagwanpur in measles outbreak in district Haridwar, Uttarakhand- March 2014

18. 18 India EIS Seminar 2014 Case control study  To examine our hypothesis and to evaluate potential risk factors for measles, we conducted a case-control study  Case: We defined a case of measle as a person with Fever and rash with any one of the following symptoms cough, coryza and conjunctivitis since 1 st November 2013 residing in the district Haridwar of state Maharashtra.  Control: A control was defined as a person residing in the district Haridwar and who did not have fever and rash since 1 st November 2013.  Cases and controls were matched by sex, village and age (age match: +/- 1 years for all below 5 years and +/- 5 year for all cases above 5 years).

19. 19 India EIS Seminar 2014 Sample size - Data collection - Data analysis  95% confidence interval, 80% power, 40% exposure in the cases, 20% in controls, and calculated by epi info case control calculation formula. It was 83 cases and 83 controls and 15% extra for non response cases.  A questionnaire was prepared to collect data on socio demographic details, clinical data, travel history, and potential exposures. The questionnaire was administered in the households of the cases and controls, in the local language.  We analyzed data using EPI info and SPSS

20. 20 India EIS Seminar 2014 Ethical Considerations This was a public health response to an outbreak and as such did not require ethical review. We protected the confidentiality of participants through use of codes and did not enter personal identifiers into the study database

21. 21 India EIS Seminar 2014 Results:1  Cases enrolled in the case control study were in the age group of 1-4 years (38/83; 46%) and 5-9 years age group (38/83; 46%); remaining cases were from above 10 years age (7/83; 8%)  Clinical presentation of cases was with fever and rash and also cough in 86% cases (71/83), coryza in 88% cases (73/83) and conjunctivitis in 83% of cases (69/83).  Cases enrolled were 47% male (39/83) and 53% female (44/83)  Socioeconomic characteristics were statistically not significant.  Also history of visit to neighboring village or to any function in last 3 months also not significant

22. IndicatorCasesControlsOdds RatioCIP value Education of child School going 57551.110.19-2.350.76 Mother education Illiteracy 75 10.34-2.90.79 Mother occupation Working 03050.50.11-2.620.71 Father Working 80820.320.01-3.130.61 House Characteristics Kaccha house 26241.120.57-2.190.86 Religion Muslim 26241.120.57-2.190.86 Economic level Low 72770.510.16-1.450.30 Economic level Median 10061.750.60-5.430.43 Economic level High 0100NA Visit to neighbor village 13081.730.67-4.650.35 Visit any function05070.690.19-2.350.76

23. 23 India EIS Seminar 2014 Results:2  Measles complication was in 12% (10/83) of cases, out of this conjunctivitis was common complication (5/10; 50%), pneumonia was in (3/10; 30%) and diarrhea was in (2/10; 20%) cases  Treatment taken by measles cases was in nearby government/ private center. 38.55% (23/83) measles cases has taken treatment, 72 %( 60/83) measles cases waited for self remittance and did not visited to any health center for any treatment.  Immunization card was available with 26.5% (22/83) cases, whereas with 38.5% (32/83) controls the immunization card was available.

24. 24 India EIS Seminar 2014 Results:3 Vaccination Results  Vaccination status in cases, for vaccine BCG (50/83; 60.24%), DPT-OPV1 (46/83; 55.42%), DTP-OPV2 (40/83; 48.19%). Whereas in controls the vaccination status was better, for vaccine BCG (60/83; 72.28%), DPT-OPV1 (60/83; 72.28%), DTP-OPV2 (40/83; 69.87%).  Number of cases vaccinated for DPT-OPV3 (32/83; 38.55%), in controls for DPT-OPV3 (57/83; 68.67%), which was statistically significant (p<0.05).  Measles vaccination in cases was 18.07 %( 15/83) and in controls it was 65 %( 54/83), which was statistically significant (p<0.05).

25. 25 India EIS Seminar 2014 Table : Vaccination history in measles outbreak case control study in district Haridwar, Uttarakhand- March 2014 Vaccination historyCasesControlsOdds RatioCIP value BCG50600.580.3-1.110.13 DPT146600.470.2-0.90.03 OPV146600.470.2-0.90.03 DPT240580.40.2-0.70.007 OPV240580.40.2-0.70.007 DTP332570.280.15-0.540.0001 OPV332570.280.15-0.540.0001 Measles 115540.120.05-0.240.0000001 Measles 200 Vitamin 115540.120.05-0.240.0000001 Vitamin 200

26. 26 India EIS Seminar 2014 Results:4 Reasons  Reasons for low vaccination was mainly no immunization sessions held during those period was statistically significant (OD: 7.5; P :< 0.05)

27. 27 India EIS Seminar 2014 Table: Reasons for low vaccination in measles outbreak case control study in district Haridwar, Uttarakhand- March 2014 Reasons for no vaccination CasesControlsOdds RatioCIP value No immunization sessions 66287.53.77-15.49<0.05 Refusal020120.15-600.62 Distance from house 00 Travel conveniences issue 00 Health staff attitude 00 Family barrier020120.15-600.62

28. 28 India EIS Seminar 2014 Conclusions  Measles outbreak was due to low immunization coverage, specially measles vaccine and vitamin A doses in the affected area  The 70% posts of ANMs in Haridwar district were vacant in the affected area since past 2-3 years and those posts were filled up ( 30%) were on strike for few months during those years, so additional immunization sessions were not held in sufficient numbers in the affected area  This year only WHO has initiated measles surveillance and they detected measles outbreak, it may be possible the same measles outbreak in the past years also in the affected areas The purpose of the study, procedures of study enrolment, risks and benefits of enrolment, and potential uses of data were explained in detail to every eligible subject. Only patients who provided written informed consent were included in the study. To ensure confidentiality and anonymity of the participants, personal identifiers (name and address) were removed from the files, and unique identifier was given Study was approved by ethical committee.

29. 29 India EIS Seminar 2014 Recommendations  ANMs post must be kept filled up either by permanent staff ( as per availability and guidelines) or by temporary staff  In place of ANMs vacant post, regular alternative additional immunization sessions must be held in the vacant post area  Measles notification and surveillance system must be strengthened and even suspect cases to be notified to the health authorities.