measles outbreak. what is this picture? case definition clinical case definition – any person in...

Measles Outbreak

WHAT IS THIS PICTURE?

Case Definition

• Clinical case definition– Any person in whom a clinician suspects measles

infection– Any person with fever, maculopapular rash, cough,

coryza, conjunctivitis• Laboratory criteria for diagnosis– 4x increase in antibody titer, isolation of measles

virus, or presence of IgM antibodies

What is considered an outbreak?

• DOH: – 1 case, suspected or confirmed, in a community

where there was no case in the past– 1 case per 2 weeks for 2 consecutive weeks

• WHO– Number of cases observed is greater than the

number normally expected in the same geographic area for the same period of time

Outbreak Timeline (Metro Manila)

25 cases2012

179 casesDec 10 2013

760casesJan 11 2014

DOH DeclaredOutbreakJan 4, 2014

21 barangaysIn 9 cities

716% increase

416 % increase

DOH statistics

Only 6% of the reported Cases are confirmed

Philippines

Year Confirmed measles cases

Incidence (per 1 million)

Deaths due to measles

2008 874 9.8 8

2009 1490 16.6 10

2010 6388 68.2 34

2011 6555 69.1 28

2012 1499 15.5 5

2013 1724 17.97 21

Source: WHO. Country Profile-Measles Elimination.

DOH National Epidemiology Center• Jan 1 – Dec 14, 2014• 1,724 cases and 21 deaths• Majority came from Metro Manila (744 cases)• 13/17 regions of the Philippines have measles case increase

• 2013 (NCR) 416 confirmed cases– 1568 % increase!

• 2012 (NCR) 25 confirmed cases• Las Pinas (78), Manila (72), Muntinlupa (65), Caloocan (45), Paranaque

(32), Malabon (31)– Urbanized, congested area– High mobility of the residents– Supposedly good EPI coverage

Source: WHO. Country Profile-Measles Elimination.

Population at Risk

• Children under age 5 years old– Higher percentage of death due to measles

complication– 158,000 people died from measles in 2011

• Pregnant women• Immunocompromised

MCV2 routine coverage: the level of coverage by the seconddose of the measles-containing vaccine, as reported in the annualWHO/UNICEF Joint Reporting Form on Immunization.

Goals

• Herd Immunity– Vaccination coverage of no less than 95%– The “Iligtas sa Tigdas ang Pinas” program in 2011

only covered 84% of the population (15,649,907) – MR vaccine• 16% (~3million) were unvaccinated or in 2 years since

at 84% coverage, 6 million were unvaccinated

• Measles Free by 2017 (WHO)– 1 case per 1 million population

Vaccination

• Measles– At 9 months– At 6 months during

outbreaks• Maternal antibodies may have

dwindled already

• MMR– 2 doses– 1 dose 90% immunity

• Booster at 12-18 (15) months

– 2 doses almost 100% immunity• At 4-6 years of age

• Some children who have been vaccinated still got infected• 2-3% may not develop

antibodies

• Some parents refuse vaccination– Religious belief– Transfer of residence

Government Response

• Vaccination– It will take a couple of weeks before they develop

immunity• Mass Immunization Campaign that aims to cover

children <5 years old (11.7 million)– Door to Door approach– All (6mo-59 mo) will be vaccinated regardless of prior

vaccination (unless does is <1 month ago) or if recently had measles

• DepEd and DOH advise voluntary quarantine

Government Response

• Mandatory Nutrition Program– FNRI: underweight children 0-5 years (3.35 million)– Significant increase in prevalence among 6-10 years old

from 22.8% in 2005 to 25.6% in 2008• Those who are malnourished are at increased risk of

dying from measles complication– Vit A supplementation can reduce mortality risk by 50%

• Tayag: “infants and children with measles should be hospitalized”– Panic among parents

Government Response

• Checking for new strain– DOH declared no new strain for this measles

outbreak

What can we expect?

• A further rise in measles cases in the coming months peaking during the summer where virus replication is faster

TMC Statistics

October November December January0

10

20

30

40

50

60

Number of Measles Cases (Admissions) from October 2013 to January 15, 2014

<1 year old 1-4 years 5-9 years 10-14 years 15-18 years0

5

10

15

20

25

30

35

40

Number of Measles Cases (Admissions) per Age Group

50%50%

Vaccination Status

VaccinatedNon-vaccinated

29%

17%

13%2%

38%

Number of Doses

1 dose2 doses3 doses5 dosesUnknown

8%

35%

19%

12%

6%

21%

Reasons for Non-vaccination

Mother was busyIneligible to receive vaccineForgot scheduleBaby was sickOthersUnknown

12%

88%

Development of Complications

Yes No

3%

28%

4%66%

Exposure History

SchoolCommunityHomeUnknown