Measles outbreak investigation & Response Jordan DR MOHAMAD RATIB SUROUR NATIONAL EPI MANAGER INTER-COUNTRY MEETING ON MEASLES AND RUBELLA CONTROL AND ELIMINATION AMMAN, JORDAN, 17-20 NOVEMBER 2013
Dec 18, 2015
Measles outbreak investigation & ResponseJordan
DR MOHAMAD RATIB SUROUR NATIONAL EPI MANAGER
INTER-COUNTRY MEETING ON MEASLES AND RUBELLA CONTROL AND ELIMINATION AMMAN, JORDAN, 17-20 NOVEMBER 2013
History • 1982 measles vaccine introduced in the national EPI at age of 9
months as single dose .• 1995 a second dose of measles was introduced at age of 18
months .• 2000 ,second dose of measles at 18 months of age was replaced
by MMR vaccine .• 2008 a second dose of MMR was introduced at age of 12 months .• Jordan was embarked on measles elimination in October
1997( after last major measles outbreak 1997)• Rubella elimination with prevention of congenital rubella
syndrome is jointed with measles elimination and mumps control 2002.
Vaccination schedule preschool -Jordan
Vaccine Age
BCG 1st contact
DaPT1 IPV1+Hib+1HepB1 2 months
DaPT2 IPV2+Hib2+HepB2+OPV 3 months
DaPT3 IPV3+Hib3+HepB3+OPV 4 months
Measles + OPV 9 months
MMR1 12 months
DPTbooster1 +OPV booster1 +MMR2 18 months
Routine Measles Vaccines in Jordan
Vaccine Age of vaccination
Type of Vaccine Year introduced
MCV1 9 M Measles 1982
MCV2 12 M, 18 M MMR 2000,2008
Jordan - EPI and vaccine preventable diseases
• All children in Jordan are being immunized against 10 dreadful diseases.
• Routine EPI coverage is sustained at 95% for different antigens.
• Jordan is measles free for 3 years before 2013. • In Feb. 2013 2 cases of measles (Syrian15 months & 14
months Iraqui ) were reported . As of now 120 measles cases reported
0
20
40
60
80
100
120
0
1000
2000
3000
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5000
6000
7000
80001979
1980
1981
1982
1983
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1989
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1993
1994
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1997
1998
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Co
vera
ge r
ate
No
. o
f cases
No. of Cases 1st dose Measles coverage
2n
Measles cases and coverage rates ,Jordan 1979 -2013
1 4 7 10 13 16 19 22 25 28 31 34 37 40 430
2
4
6
8
10
12
Measles Epidemic Curve by weeks & na-tionality /Jordan/2013
Jordanian Syrians Irakians
Zarka
Ramtha
Zaata
riIrb
id
Banek
enan
a
Amman
Mafrak
Deir Alla
Balka
Madab
aKara
k0
10
20
30
40
50
60
IrakiessyrianJordanian
Measles cases by districts & nationality
Incidence rate of measles by districts
Amman Madaba Zarka Balka Irbid Ramtha Banekena Mafrak Karak Deir Alla Zaatari0.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
160.0
I.R /1000000
<1 year 1-4 5-9 10-14 15-19 20-24 25-29 >30 years0
5
10
15
20
25
30
35
IrakiessyrianJordanian
Measles cases by age group & nationality
Measles cases by vaccination status & nationality
Jordanian Syrian Irak0
10
20
30
40
50
60
70
un known un vaccinatedvaccinated
Measles outbreak response :
• Rapid Response Team• Line list of suspected measles cases with follow up the contacts • Detecting the index case• Lab: Sampling ( Blood sample and throat swab) • Map for area with cases distribution• Control measures (case isolation, treatment, Health education and
outreach activities) • immediate reporting of newly cases• Epidemic curve• Report• Documentation
Outbreak response • Emergency measles outbreak response:
– Vaccination around the case – April- May 2013: Measles/Polio/vitamin A campaign at
Zaatari and EJC camps (covering 71,000 individuals up to 30 y).
– June-July 2013: out of camp Measles/Vitamin A campaign in 2 Governorates bordering Syria and Iraq (covering 622,000 children up to 15 y).
– November 2013: Measles/Rubella/Polio/Vitamin A campaign is going on:
Campaign results – administrative data
*Note: Higher reported coverage among the Syrian population may be due to less accurate population target estimates - population change due to their mobility (i.e. some may be registered in Amman, but reside in Irbid or Mafraq), or they may be un-registered.
Jordanians(n=532,908)
Syrians(n=73,177)
Total(n=606,085)
Irbid 99% 115% 100%
Mafraq 106% 139% 111%
0%
20%
40%
60%
80%
100%
120%
140%
160%Re
port
ed A
dmin
istr
ative
Cov
erag
e
Measles Vitamin A
Irbid (n=819) 89.7% 88.0%
Mafraq (n=850) 89.6% 88.1%
Total (n=1669) 89.7% 88.0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Estim
ated
Pos
t-Ca
mpa
ign
Cove
rage
Results of PCES
• Overall 898 houses were visited
• Data from one child per age group were used in the analysis
• 1,669 children– Irbid (819 children)– Mafraq (850 children)
PCES – Nationality and Age Group
Nationality
Jordanians 90.2%
Syrians 85.6%
Total 89.7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Estim
ated
Pos
t-Ca
mpa
ign
Cove
rage
Age
6m-<60m 91.1%
5y-<10y 92.0%
10y-<15y 85.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Estim
ated
Pos
t-Ca
mpa
ign
Cove
rage
* In Irbid, coverage was significantly lower among children 10–14 years of age than in children 6–59 months or 5–9 years
Coverage among Syrian children was lower compared to Jordanian children, but the difference was not statistically significant.
MR-P Campaign / 2-21 Nov.2013
• MR Age group targeted = 6 M – 20 years • OPV Age group targeted = 0 – 59 M• Vit .A Age group targeted = 6 M – 59 M Campaign strategy : - through fixed teams at health centers - outreach teams in the Universities, schools ,
NGOs ,Malls . . Etc. - mobile teams to hard to reach and mobile
populations
• Due to polio situation in Syria we have now competing priorities regarding the measles & Polio which implicate to combine the improvement of AFP & measles surveillance and all other activities related
Lessons learned - 1
• Frequent advocacy meetings and coordination among all partners allowed for good communication and improvements throughout the campaign
• Close collaboration with UNHCR and NGOs resulted in high coverage among Syrians during the campaign– Specialized strategies for reaching Syrian children needed
• Intensified supervision structure allowed for careful monitoring and correction of any issues that arose – Also allowed for immediate action to be taken by the
campaign teams• Daily supervisory tour plans and checklists provided
transparency and accountability
Lessons learned - 2
• The Measles Control Rooms were critical to the success of the campaign– Managed vaccine distribution– Daily contact with the supervisors– Identified problems in the field and took
immediate action
Lessons learned - 3
• RCA is an important tool to find pockets of missed children and guide social mobilization efforts throughout the campaign
Challenges
• Intensifying measles rubella surveillance ( combined with AFP surveillance ,surveillance officers for AFP
and Measles –Rubella surveillance .• Negative media ( communication group ) for preparing bilingual
messages ) • Reaching the older age groups of universities and schools
students( meetings with students unions leaders , sending messages through the SMS, through media youth radios ..)
• Competing priorities ( combining both activities for AFP & measles )
• Reaching the un registered Syrians ( through the IOM and other NGOs dealing with Syrian refugees ).