Verdana: AFP & MEASLES SURVEILLANCE Dr. Anish Sinha State Surveillance Medical Officer World Health Organization National Polio Surveillance Project Gandhinagar. Arial: 1988 350 000 cases 125 countries Areas with Active Polio Transmission Tahoma: India Pakistan Afghanistan Nigeria Polio Endemic Countries Calibri: Location of poliovirus by type, 2010* Most recent virus 7 February 2010 Jammu, J&K * data as on 19 March 2010 Comic Sans MS: Location of poliovirus by type, 2009* ** One case reported mixture of P1 wild & P3 wild * data as on 19 March 2010 Symbol: Location of poliovirus by type, 2008 Monotype Sorts: Location of poliovirus by type, 2007 ** three cases (one in UP, two in Bihar) reported mixture of P1 wild and P3 wild Wingdings: Polio cases, India P1 wild P3 wild * data as on 19 March 2010 NPSU: Polio type 1 Microsoft Excel Chart: Polio cases of type 1, India Year * data as on 19 March 2010 Microsoft Graph 2000 Chart: Polio cases of type 1, Uttar Pradesh Year * data as on 19 March 2010 Microsoft Office Excel Worksheet: Polio cases of type 1, Bihar Year * data as on 19 March 2010 Microsoft Graph Chart: Sustained intensification in the access compromised areas around Kosi river Grid areas: Groups of villages from different districts clustered in hard to reach riverine areas Dedicated SMOs, field volunteers and social mobilizers assigned to each grid to support microplanning, training, community mobilization and monitoring Bitmap Image: 2005 - 1 Gujarat Wild Cases 2000-09 BAN KTC JMC RJC AML BVC KDA PML DHD VDD SRC NAV DNG AMD AND VDC SRN GNR VLD AMC NMD BRH SBK BVN JUN PAT MSN JMD POR SRT RJT 2002 - 24 2003 - 3 2001 - 1 2004 - 0 Year - Cases 2000 - 2 2006 - 4 2007 - 1 2008 - 0 2009 - 0 AFP & MEASLES SURVEILLANCE : Strategies of Polio Eradication 1985 – Routine immunization Individual immunity 1995 – NID’s ( PPI / IPPI ) To replace wild with vaccine virus 1997 - AFP surveillance To identify reservoir of transmission 2000 – Mopping up immunization To eliminate last foci of transmission PowerPoint Presentation: Objective of AFP surveillance Reliably detect areas where polio transmission is occurring or likely to occur PowerPoint Presentation: Principle of AFP Surveillance in identifying polio cases Identify children with the SYNDROME of Acute Flaccid Paralysis Acute - Sudden onset, Rapid progression Flaccid - Floppy or Soft and yielding to passive stretching at anytime during the illness . Paralysis is loss of strength of muscles, Severe loss of motor strength is called paralysis or plegia Paresis- less severe loss of motor strength PowerPoint Presentation: Definition of AFP for surveillance purposes Sudden onset weakness and floppiness in any part of the body in a child < 15 years of age or paralysis in a person of any age in which polio is suspected. PowerPoint Presentation: Logic of AFP investigation & stool sample collection Sensitivity increases when all AFP cases are investigated Testing of stools of all AFP is the most valid test for identification of Polio ALL cases with ‘Acute Flaccid Paralysis’ should be reported and their stools must be tested!! Even if other ‘tests’ (CT scan, MRI, etc.) or additional clinical information point to other diagnoses, their stools must be tested to rule out Polio PowerPoint Presentation: Reporting All cases of acute flaccid paralysis should be reported immediately ALL AFP cases reported within 6 months of onset of paralysis should be investigated All reporting units, informers and other contacts should continue to report AFP cases as per existing case definition – there is no change in the definition PowerPoint Presentation: Action when AFP is reported FIRST – Start stool collection process Investigate - SMO/ DIO - Confirm if AFP,if not reject case and record the same . There is only one category of cases - AFP Allot EPID number & Report the case as AFP CIF & LRF should be filled . Use the revised CIF/ Linelist form . Ensure that stools are transported to lab in cold chain NPSU will Classify after lab result is received Give feedback to the source that the AFP reported was/ was not polio. Maintain documentation at ALL levels. PowerPoint Presentation: Therefore… The basic system of AFP surveillance remains unchanged To enhance sensitivity, all cases of acute flaccid paralysis should be reported and investigated Borderline cases should be included and stool specimens tested PowerPoint Presentation: The AFP Surveillance System Hospitals Clinics Community Investigation Non-Polio AFP Polio AFP PowerPoint Presentation: When too much polio is around ….. Non-AFP cases Polio cases AFP cases Borderline AFP cases Surveillance sensitivity is adequate enough to detect 90% polio cases PowerPoint Presentation: When transmission is very low….. Non-AFP cases Polio cases AFP cases Borderline cases Surveillance sensitivity is not good enough & detects only 50% polio cases …Sensitivity increases and leads to 100% detection of polio cases If borderline cases are taken & stool specimens collected … Remember Non AFP cases still not taken PowerPoint Presentation: Differential diagnosis? Poliomyelitis Guillian Barre Syndrome Transverse Myelitis Traumatic Neuritis Hemiplegias / Hemipaeresis Fascial palsy Palatal palsy Others PowerPoint Presentation: STOOL COLLECTION, STORAGE , TRANSPORT . Adequate Stool. 2 Specimens 24 Hours Apart. 8 gms. Within 14 Days of Paralysis Onset Proper Cold Chain and Condition. Procedure. Errors. Storage(Delayed Second Sample) Cold Chain. Rectal Tube. Transport.(PHN & HA) Death of AFP Case.( Spinal Cord , Intestinal Content) PowerPoint Presentation: GOLD STANDARD FOR AFP SURVEILLANCE Non – Polio AFP Rate > 2.0 Adequate Stool Samples > 80% Timeliness of Reporting > 80% Strategies of Polio Eradication: VIROLOGIC CLASSIFICATION SCHEME * 2 SPECIMENS, AT LEAST 24 HOURS APART AND WITHIN 14 DAYS OF PARALYSIS ONSET; EACH SPECIMEN MUST BE OF ADEQUATE VOLUME (8-10 GRAMS) AND ARRIVE AT A WHO ACCREDITED LABORATORY IN GOOD CONDITION (i.e. NO DESSICATION, NO LEAKAGE, ADEQUATE DOCUMENTATION AND EVIDENCE THAT THE REVERSE COLD CHAIN WAS MAINTAINED) NO WILD POLIOVIRUS AFP WILD POLIOVIRUS INADEQUATE STOOL SPECIMENS TWO ADEQUATE* STOOL SPECIMENS NO RESIDUAL WEAKNESS CONFIRM COMPATIBLE DISCARD DISCARD RESIDUAL WEAKNESS, DIED OR LOST TO F/U DISCARD EXPERT REVIEW PowerPoint Presentation: Compatible Cases 2002-2009 2002 – 14 cases 2003 – 4 cases 2004 – 1 case 2005 – 7 cases 2006 – 3 cases 2007 – 5 cases 2008 – 1 case 2009 – 0 case PowerPoint Presentation: HOT CASE A case of AFP with any of the following set of conditions - Age less than 5 year plus history of fever at onset plus asymmetrical proximal paralysis. Age less than 5 year with rapidly progressive paralysis leading to bulbar involvement (cranial nerves are affected) and death. Any case which in the opinion of SMO/DIO looks like polio. PowerPoint Presentation: CONTACT SAMPLES To be considered for cases fulfilling criteria like Hot cases, but adequate samples from case could not be taken Such cases or any other situations where SMO / DIO feels the necessity of contact samples, should be discussed with RTL NPSP PowerPoint Presentation: Month wise Cases Reported by Ahmedabad Muni.Corpn. PowerPoint Presentation: Month wise Cases Reported by V.S.Hospital, Ahmedabad Muni.Corpn. PowerPoint Presentation: Cases Reported by Ahmedabad Muni.Corpn. PowerPoint Presentation: Cases Reported by diiferent RUs of Ahmedabad Muni.Corpn. PowerPoint Presentation: Cases Reported by Civil Hospital of Ahmedabad Muni.Corpn. PowerPoint Presentation: Cases Reported by V.S. Hospital of Ahmedabad Muni.Corpn. PowerPoint Presentation: Cases Reported by L.G. Hospital of Ahmedabad Muni.Corpn. Differential diagnosis?: Cases Reported by Shardaben Hospital of Ahmedabad Muni.Corpn. STOOL COLLECTION, STORAGE , TRANSPORT.: MEASLES GOLD STANDARD FOR AFP SURVEILLANCE: Top Ten Causes of Death in Children Aged <5 Years, Worldwide, 2000 Source: World Health Organization, Global Burden of Disease 2000Project Measles is the biggest Killer among VPDs! VIROLOGIC CLASSIFICATION SCHEME: Measles virus and measles One serotype virus – morbillivirus Spreads via droplets / aerosol Causes: measles, SSPE Also: encephalomyelitis; pneumonia Many secondary effects (Complications) Major cause of death (direct, indirect) One infection, lifelong immunity PowerPoint Presentation: Measles: Clinical features Incubation period from exposure to onset of fever is usually 10 days. Initial symptoms and signs are high fever, runny nose, coryza, cough, red eyes and Koplik spots (small white spots on the buccal mucosa). Characteristic erythematous (red) maculopapular (blotchy) rash appears on the 3rd to 7th day, starting behind the ears and on the hairline and then spreading to the rest of the body. Temperature subsides after 3–4 days; the rash fades after 5–6 days. Measles is highly infectious from the start of the prodromal period until approximately 4–5 days after the rash appears. CONTACT SAMPLES: Complications Complications develop in up to 30% of cases. Complications occurring in the first week of illness, such as croup, diarrhoea and pneumonia, are usually due to effects of the measles virus and are rarely life-threatening. Later complications are usually due to secondary viral or bacterial infections – post measles pneumonia, diarrhoea and croup are the most common life-threatening complications Vitamin A deficiency: Keratoconjunctivitis. Measles increases the need for vitamin A and often precipitates xerophthalmia. PowerPoint Presentation: Blindness due to scarring, as a result of vitamin A deficiency and/or conjunctivitis. Encephalitis: caused by the measles virus itself, occurs on about the 5th day of the rash. Otitis media Uncommon: Myocarditis, Pneumothorax, Pneumomediastinum, Appendicitis, Subacute Sclerosing Panencephalitis Case–fatality rates are estimated to be 3–5% in developing countries but may reach as much as 10–30% in displaced populations. CFR in India: 0 - 23.9% (Median 3.7%) Complications… PowerPoint Presentation: Prevention: Measles vaccine Indian vaccine Edmonston-Zagreb 1000 to 5000 TCID 50 Maternal antibody inhibition Given at 9 months Vaccine efficacy - 85%. Effectiveness = coverage X VE e.g …… 80% coverage at 9 mos = 80X85 = 68% Cases Reported by Ahmedabad Muni.Corpn.: Measles Control: Current Strategies in India Passive surveillance Data not used for local action Limited epidemiological data (Seasonality, Age distribution, Geographical incidence, Age specific incidence) Integrated disease surveillance program Measles laboratory at PII Coonoor, KIPM Chennai,NIV Bangalore, IPM Hyderabad, NICD Delhi & NIV Pune Network of labs not fully established Cases Reported by diiferent RUs of Ahmedabad Muni.Corpn. : GOI Measles Strategic Plan Key Features of the Plan Strengthen RI: Achieve 90% coverage Strengthen Surveillance Outbreak Investigations- Standard guidelines Lab confirmation of Cases Active Surveillance Data to guide action Standard guidelines for Case Management SIA in states with 90% coverage Cases Reported by Civil Hospital of Ahmedabad Muni.Corpn. : Measles Mortality Reduction Strategies Achieve high 1st-dose routine vaccination coverage Effective disease surveillance Improved Case Management Vitamin A supplementation Provide 2nd opportunity for vaccination through routine or supplemental activities Cases Reported by V.S. Hospital of Ahmedabad Muni.Corpn. : Measles Surveillance Cases Reported by L.G. Hospital of Ahmedabad Muni.Corpn. : Objectives of Measles Surveillance Detect all areas of measles virus circulation, in a timely manner Detect and investigate suspected measles outbreaks Identify high-risk populations/areas for measles Strengthening measles immunization coverage in these areas Monitor progress in reduction of measles mortality Cases Reported by Shardaben Hospital of Ahmedabad Muni.Corpn. : Measles Surveillance Activities Case Definition Activities at reporting site level Activities at district level Activities at state level MEASLES: Case Definition of Clinical Measles Any person in whom clinician suspects measles infection or Any person with fever and maculo papular rash with cough or coryza (running nose) or conjunctivitis (red eyes) For epidemiological investigation, clinical measles would be a case within last 3 months Top Ten Causes of Death in Children Aged <5 Years, Worldwide, 2000: Measles Meningococcemia Rubella Roseola infantum Other viral exanthems Rash + Fever Toxoplasmosis Mononucleosis Dengue Kawasaki Scarlet fever Measles virus and measles: Key Information to be Collected on Clinical Measles Cases by Reporting Sites Person Age Vaccination status (+ date of last vaccination) Place Residence at time of rash onset Time D ate of rash onset = “Date of Onset” Objective is to detect clustering of clinical measles cases and initiate outbreak investigation Detection of clustering is done at district level PowerPoint Presentation: Phone Messages/ Active Searches/ Weekly routine reports for detection of suspected Measles cases Preliminary Search in adjacent areas Outbreak investigation to Collect Data, Confirm outbreak and Provide Vit- A, Care and Referral to affected Complications: Operational criteria for conducting extensive outbreak investigation > 5 clinical cases of measles in a block in a week OR > 1 death due to measles OR > 5 clinical cases in an area bordering a block with continuous areas Remember Measles never occurs as an isolated case. Decision to investigate an outbreak should be taken at District Level Complications…: Desk Review of Measles data every Tuesday at district level Identify blocks with 5 cases or 1 death in a week Which potential outbreaks to investigate? Any Death in a block 5 cases in a block If yes, ASSIGN OUTBREAK ID & conduct preliminary field search in area to look for additional cases Assess if these cases are clustered in same/ adjacent villages If additional cases found (~20 cases), conduct detailed investigation Prevention: Measles vaccine: Measles and vitamin A Low vitamin A levels: ~ higher rates of complications & deaths Synergy of measles & vitamin A deficiency have additive pathological effect on epithelia and immune system This synergy causes ~ 1 million deaths Measles itself may lead to severe acute depletion of vitamin A Precipitates keratomalacia & blindness Role of Vitamin A in measles 2 doses reduce mortality by 48-81% Measles Control: Current Strategies in India: GoI recommended Vitamin A schedule for treatment of measles Age Immediately on diagnosis Next day < 6 months 50,000 IU 50,000 IU 6 – 11 months 1,00,000 IU 1,00,000 IU > 12 months 2,00,000 IU 2,00,000 IU 2 dose schedule is more effective than single dose schedule GOI Measles Strategic Plan: Summary: Basic Principles of management Anticipate complications Encourage breast feeding Provide nutritional support to all children Administer vitamin A Give paracetamol if temperature exceeds 39°C Give ORS for diarrhoea Treat eyes promptly to prevent blindness Use antibiotics if indicated Admit severely ill children Monitor growth regularly Measles Mortality Reduction Strategies: National Polio Surveillance Project (A GOI & WHO Collaboration) SMO : DR. Anish Sinha CONT.NO. (OFF) 079-23226982 (Mobile) 9377470505 Mail: firstname.lastname@example.org Measles Surveillance: Thank You !