Components of present Measles

-Rubella surveillance system

State case-based MR surveillance transitioning and VPD surveillance launch

workshop
 Measles-Rubella Surveillance - India

Uses Acute Flaccid Paralysis (AFP) Surveillance as

the weekly suspected-MR case reporting platform

Supported by WHO accredited laboratory network

At present it involves investigation of suspected

M-R outbreaks & detects area of transmission
 Currently, Measles-Rubella Surveillance :

Generates evidence on age distribution

Provides immunization status among cases

Identifies under-immunized pockets for corrective

action, through RI strengthening

Helps informed policy decisions: susceptible cohort

etc. to guide immunization programme
Measles / Rubella Lab-Network, WHO-NPSP
12 - National laboratories
2 - Reference laboratories

PGI, Chandigarh
SGPGI, Lucknow
PMC, Patna
NCDC, Delhi
SMS, Jaipur
GMC, Bhopal
BJMC, Ahmedabad
NIV, Pune
NIV, Bangalore
KIPM, Chennai
IPM, Hyderabad
IOS, Kolkata
MCG, Guwahati

14 established WHO accredited M/R Laboratories with their catering areas & 1 New Lab (ERC Mumbai catering area not decided )
 MR Surveillance reporting network in the
country
Combined AFP-MR reporting

Quack Other
14% 1%

Govt.Allopathi
ISM* c
Practitioner 34%
8%

Pvt.Allopathic
44%

*Indian System of Medicine

N = 41383
Reporting Units (11,557): Send a report of AFP / suspected Measles cases, weekly
Informing Units (29,826): Inform as and when they see AFP/suspected Measles case
5
 Reporting Network : Himachal Pradesh
200
Rus Informers
175 178 178
180 163
160 146
140 120 120 123 124 124 124
123
120
118 119 119 119 119
100
79 88
80 85 85 65
85 69 71 73
56 56
78 78 56 56
60

40

20

02

03

04

05

06

07

08

09

10

11

12

13

14

15

16

17
20

20

20

20

20

20

20

20

20

20

20

20

20

20

20

20
VHP=21
HP=51
LP=229

Reporting Units
Informing Units

Government-allopathic Private-allopathic Other

Components of MR surveillance
Case definition of suspected measles

Any person with fever and maculopapular rash

with
Cough or
Coryza (running nose) or
Conjunctivitis (red eyes)
or
Any person in whom a clinician suspects
measles infection
For field epidemiological investigation, suspected measles
would be a case within last 3 months (90 days)
 Definition of suspected measles death

A death which occurs within one month of

onset of measles
Wherever possible a secondary cause of death is
defined like diarrhea, acute respiratory infection or
malnutrition
Even though a death may appear to be from other
causes (e.g. diarrhea) it is counted as a measles
death if it occurs within one month (30 days) of
onset of measles rash

Source: The Global Epidemiology of Infectious Diseases. WHO 2004

Components of Measles surveillance

Reporting network reporting units and

informers
Data flow and analysis
Detection of potential outbreaks of measles
Investigation and confirmation of measles
outbreaks
Case management
Consolidation of data from all outbreaks at
district and state/UT level to decide
immunization strategy
 Reporting of suspected Measles cases
Who reports : All reporting sites ( Reporting units and
informers) participating in AFP surveillance
What : Cases of suspected measles
When : Reporting units - every Monday ; informers
whenever they get a case
How : Through weekly reporting format VPDH002
To whom : BMO & DIO
Data matching : CHC BMO to match & collate the case
information from multiple sources including IDSP
Data sharing : DIO and DSO to share their information on
suspected measles cases every week mismatch to be
minimised / eliminated
Nil report to be sent even if no case is seen in the last week
Key information to be collected on suspected
Measles cases by reporting sites
Person : Name, Age
Place: Residence at time of rash onset
Time: Date of rash onset = Date of Onset

Status of the case at the time of reporting

Vaccination status
Alive or dead
Samples collected
 Measles case reporting protocol

Suspected Measles Block nodal person enters

case identified by details of the case in VPD
RU/IU/field H002

BMO signs the VPD H002

Reported to
DIO/ SMO & VPD H002 send to district
BMO/ block
nodal person
District nodal person enters in VPD D001

VPD D001 is sent to the state for DIO reviews report, cross checks with
incorporation in VPD S001 IDSP report & signs VPD D001
 Algorithm for potential outbreak
investigation
Potential outbreaks identified based on desk
review of weekly reports of all sporadic cases
(Every Tuesday)
Both DIO and DSO together look at data from AFP
reporting system & data from IDSP
Potential outbreaks are flagged with outbreak ID,
when there is a case-clustering in time and place
WHO SMOs support in capacity building and
carrying out field investigation
Triggers to flag a potential outbreak with
ID ?
> 5 suspected cases of measles in a
block/planning unit in 4 weeks duration
OR

> 1 suspected measles-death in a block/planning

unit in 4 weeks duration
OR

> 5 suspected cases in an area bordering multiple

contiguous blocks/planning units in 4 weeks
Present MR outbreak surveillance model :
Desk Review of Measles data every Tuesday at district level

Identify blocks/ planning unit with >5 suspected cases or > 1

death in 4 - weeks time

ASSIGN MEASLES OUTBREAK ID (MOB-IND-ST-DIS-YY-NUM)

& conduct Preliminary investigation to identify
clustering

If ~ 5 suspected cases are clustered in a contiguous area -

village/ward, then mobilize ERT & conduct detailed outbreak
investigation with H to H case search, line listing of all cases with core
variables & unique case-ID, and sample collection
Steps in Potential outbreak investigation
Pre investigation planning meeting at block/PHC
House-to-house case search by health workers
team
Blood sample collection from 5 cases for
serological testing (4 to 28 days)
Throat swab and urine sample from selected
cases - for genetic characterization (0 to 5 days)
Two doses of vitamin A for all suspected case 24
hours apart
Case management with ORS, antibiotics and
referral (post measles complications) under
medical supervision
 WHO M/R Laboratory testing protocol

Suspected Measles Case Measles IgM serum

Positive Negative

Confirmed measles

Rubella IgM

Negative Positive

Discard Confirmed Rubella

Few samples of throat swab and urine for viral isolation and genetic characterization from each outbreak
 MR outbreak classification protocol
(Based on Ig M serology results)

IgM results of samples collected from an Classification of

outbreak Outbreak

> 2 measles positive and <2 rubella positive Measles

> 2 rubella positive and <2 measles positive Rubella

> 2 measles positive and > 2 rubella positive Mixed

Negative for
<2 measles positive or <2 rubella positive
measles & rubella
 Outbreak surveillance indicators
Timeliness of reporting:
Proportion of surveillance units reporting on time ( 80%)
Completeness of reporting:
Proportion of reporting units completed all due reports ( 80%)

Suspected outbreak flagging for investigation:

Proportion of suspected outbreaks identified and flagged for
investigation along with an MOB-ID (100%)
Percentage of suspected measles outbreaks fully investigated [
80 %]
Percentage of outbreaks tested for virus strain detection [ 80%]

Laboratory confirmation from suspected outbreaks:

Percentage of specimen with laboratory results within 4 days
[ 80%]
 Challenges in M-R surveillance

Poor health seeking behavior for Measles

Only serious post measles complications like
pneumonia, diarrhea, encephalitis, blindness
comes for treatment to health facilities - but
late
So what we see is just the tip of the ice-berg
and true disease burden is always hidden
Limitations of the current outbreak based
surveillance system

All sporadic cases are not part of the line list

Not all suspected MR cases get lab-confirmation

A large proportion of our line-list is Epi-linked

Only outbreaks with more than 5 case clustering are

investigated and line-listed as per present protocols

One time data collection during outbreak

investigation and are not followed up till last case
 Summary

Standardized case and outbreak definitions in all states

Unique outbreak ID along with case ID for all cases, from
within investigated outbreaks
Standardized WHO accredited MR lab network for all
states
Global standards for case and outbreak classification
Genetic characterization of circulating measles /rubella
viruses to strengthen genetic data base
Transitioning to case based surveillance is an absolute
requirement in Elimination setting