Measles outbreak and vaccination Universidade.pptx

Vacinação contra sarampo

1. U niversídade Católica de Moçambique Departamento de Medicina-FCS  Measles outbreak and vaccination 4 o ano Agosto/2024 Akú Júnior Macuácua Médico GP Mestrando Medicina Tropical

2. Measles vaccination averted 57 million deaths being between 2000 and 2022. Even though a safe and cost-effective vaccine is available In 2022 , there were an estimated 136 000 measles deaths globally (mostly among unvaccinated or under vaccinated children under the age of 5 years) The proportion of children receiving a first dose of measles vaccine was 83% in 2023 , well below the 2019 level of 86%.  In 2023, 74% of children received both doses of the measles vaccine. Epidemiology Source: WHO: 2023. DOI: http:// dx.doi.org /10.15585/mmwr.mm7246a3

3. Epidemiology

4. Measles cases: Mozambique 949 cases 884 cases 676 cases 664 cases 230 cases 2020 2021 2022 2023 2024 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 200 400 600 Number of measles cases SIA Discarded Clinical Epi Lab 50 100 150 200 20 40 60 <1 yr 1-4 yrs 5-9 yrs 10-14 yrs 15-24 yrs 25-39 yrs 40+ yrs Age at onset (in years) Number of cases Incidence rate per M Incidence 2+ doses 1 dose 0 doses Unknown Age distribution, vaccination status and incidence (last 12 months) 20 40 60 80 100 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 % Coverage MCV1 MCV2 WHO/UNICEF Coverage Estimates (WUENIC) ELIMINATION STATUS: ENDEMIC Based on data received 2024-08 - Data Source: IVB Database. Main epi curve was built using case-based surveillance data. Age distribution curve was built using case-based surveillance data. Coverage data from WHO/UNICEF Estimates of National Immunization Coverage (WUENIC)

5. Measles disease Cause: highly infectious measles virus Transmission: person-to-person or direct contact with infected secretions 7 to 14 days after exposure: Fever (peaks at 39°– 40.5 °C) Rash (maculopapular) Cough, coryza (runny nose), conjunctivitis (red eyes)

6. Clinical course of measles What is the incubation period? Ranges from 7 to 14 days When is the person most infections? 4 days before rash and 4 days after rash onset When does the rash appear? 2 to 4 days after the early symptoms appear (fever, cough, coryza, conjunctivitis) When do the complications occur? During 30 days after the rash onset (mostly in the 2 nd and 3 rd week)

7. Measles complications In about 30% of reported cases Risk for severe complications greater in: Children ˂5 years in overcrowded living conditions, if malnourished or with vitamin A deficiency Children with immunological disorders (e.g. advanced HIV infection) Adults ˃20 years of age Case-fatality rate: Usually 3–6% In developed countries rare, usually 0.01–0.1% In humanitarian emergencies up to 30%

8. Most severe measles complications Pneumonia 1 st most common cause of death Diarrhoea 2 nd most common cause of death Blindness (due to scaring of cornea) In areas with vitamin A deficiency Post-infectious encephalitis 1–4 per 1000–2000 cases Subacute sclerosing panencephalitis (SSPE) 1 per 10 000–100 000 cases (several years after the infection) Death (CFR) Usually 3–6% but can be up to 30% in humanitarian emergencies

9. Clinical treatment of measles-1 For all suspected measles cases in children <5 years of age Irrespective of the timing of previous doses of vitamin A, administer: 1 dose of vitamin A on diagnosis 2 nd dose of vitamin A the next day 3 rd dose of vitamin A 4-6 weeks later if signs of deficiency show Source: WHO guidance: https://www.who.int/immunization/documents/9789240002869/en/

10. Careful care of eye, mouth and skin (necessary to prevent secondary infections) Ensure adequate nutrition Complications: to be treated using the same standards used in non-measles patients Clinical treatment of measles-2 Source: WHO guidance: https://www.who.int/immunization/documents/9789240002869/en/

11. Symptomatic treatments

12. Very contagious airborne spread by infectious person coughing and sneezing . Can remain infectious in environment for several hours Overcrowding in camp Measles more common and more severe in: Unvaccinated people Immunocompromised Malnourished Vitamin A deficiency Why is measles so infectious in a refugee camp?

13. Vaccination Campaign Normally Vaccination Campaign  Efficacy - Vaccine protects 85% of child vaccinated at 9 months , Target population: Recommended age of vaccine usually 9 months- 2-5years

14.  Planning programme Organisation first of rapid mass campaign coupled with: Vitamin A supplementation Routine immunisation programme WHO case definition of measles: generalised macular popular rash >3 days and fever >38, with at least one of the following – cough, coryza, conjunctivitis. Setting up a Mass Vaccination campaign  In refugee camp

15. Setting up a Mass Vaccination campaign  In refugee camp  Estimate size of target population. Define vaccination strategy Assessment of need – vaccine quantity (order via UNICEF/national EPI) Consider size of target population - usually 6 months -15yrs = 35% of total population: Aim for 90-100% coverage Assume 15% vaccine loss during a mass campaign Need 25% reserve vaccines to be held in stock Organisational issues (equipment “cold chain”, staff and site)

16. In refugee camp, recommended to Extend target group in refugee situation 6 months to 15 years target children in host community in close contact Low efficacy 6-9 months therefore second dose after 9 months Care with older girls – vaccine contraindicated in pregnancy (live attenuated virus) NB. NOT CONTRAINDICATED IN : malnutrition/HIV/AIDS/previous measles vaccine or infection/fever/diarrhoea Setting up a Mass Vaccination Campaign

17.  Selective vs non selective vaccination Selective = check status on basis of a card. Non selective = vaccinate everyone regardless. NB. Non selective preferred because more rapid and little chance for error ( second dose no adverse effect but provides better protection ). Setting up a Mass Vaccination Campaign  In refugee camp

18. Need system for maintaining immunization (integral part of health care activities) Children who missed first campaign New arrivals Children who were 6-9months at first vaccine New groups of children reaching 6 months. Best way is to set up fixed vaccination points in existing health services and screening centre . Why is there a need for ongoing vaccine programme? In refugee camp

19. Measles outbreak: risk assessment

20. OBJECTIVES Determine the cause and extent of confirmed measles outbreaks. Identify potential measles contacts to target those at particular risk of disease for intervention  Outbreak response immunization: Reduce the extent and duration of the outbreak and interrupt transmission.  Treatment: Reduce measles morbidity, mortality, complications and sequelae  Prevent outbreaks:  Implementation of appropriate public health strategies to control further transmission Investigating Measles outbreaks In refugee camp

21. Investigating measles outbreaks In refugee camp

22.  If outbreak occurs before mass immunization: Vaccination may reduce severity of disease if administered within 3 days of exposure (even among already exposed people)  Role of Vitamin A: reduces severity of illness and case fatality, corrects Vitamin A deficiency (2 nd vit A dose should be avoided) Role of vaccine in outbreaks

23. Can we stop measles? At least 95% of the population immunity needed! Immunity: naturally acquired (after measles disease) or through vaccination. Two doses of Measle vaccine are needed to ensure high population immunity because: After the 1 st dose , 10-15% of infants do not develop protective immunity to measles (primary vaccine failure) After the 2 nd dose , 95% of infants who did not respond to the 1 st dose develop protective immunity to measles. 23

24. Therefore, there will always be some individuals who remain susceptible to measles BUT When population immunity is high and transmission of measles virus is interrupted, susceptible do not get measles . Can we stop measles?

25. Who is in the vaccination team? All vaccination teams must have the following: Skilled vaccinator (at least 1) Trained volunteer/team assistant (1–2) Announcer/social mobilizer (at least 1) Supervisors 25

26. Cold chain of Measles vaccines 2 to 8 °C

27. How do you store vaccines and diluents at the health facility? Cold box can also be used for storage: if handled properly, it can maintain the needed 2-8 °C temperature up to 6 days. Source : https://www.who.int/immunization/diseases/measles/SIA-Field-Guide.pdf

28. Packing the vaccine carrier

29. Always remember: Keep Measle vaccine away from Light , especially direct sunlight Any source of heat . Reconstituted Measles vaccines quickly lose their potency if exposed to the room temperature or light: After 1 hour at 20 °C , it loses about 50% potency After 1 hour at 37 °C , it loses about 100% potency. Reconstituted Measle vaccine must be stored away from light (i.e. in the foam) at 2-8 °C and discarded after 6 hours or at the end of the vaccination session, whichever comes first.

30. Vaccine Vial Monitor (VVM) Measle vaccine vials have the VVM on top. VVM monitors cumulative exposure to heat and the colour of the inner square changes accordingly. Always check VVM and vaccine expiration date!

31. To use or not to use?

32. What is a good location for SIA vaccination session? Easily accessible to local community Adequate space in the shade for 3-5 health workers and volunteers to work Adequate furniture (tables, chairs) Separate entry and exit points Shaded waiting area for parents (also for 15 min observation after vaccination – AEFI with rapid onset) Well marked with flag, banner or poster

33. Client flow in a vaccination session (Measle vaccine only) Entrance VACCINATION Check for contraindications Ask about previous AEFI Vaccinate with M/MR Educate: Inform on possible AEFI, next RI dose, etc. RECORDING Mark tally sheet and vaccination card Finger marking Advise to wait 15 min in case of AEFI Exit Vaccinator Team Assistant/ Volunteer REGISTRATION Confirm age/screen Team Assistant/ Volunteer

34. Administration of subcutaneous injection

35. Safe injection disposal Drop the used AD syringe needle-end down into the safety box, immediately after use. Never recap the needle . 35

36. After vaccine administration Vaccinator should: Inform the mother/caregiver about possible adverse reaction and when they may occur Advise the mother/caregiver about child’s next routine vaccinations Volunteer/team assistant should: Mark tally (cross the circle in the tally sheet Ø) Mark left little finger with indelible ink pen Mark vaccination card or home-based record, if applicable Advise the mother/care give r to remain at the session site for 15-20 minutes , preferably seated, in case of AEFI with rapid onset

37. Adverse events following measles vaccination Measles vaccine is very safe Most AEFI observed after measles vaccination are mild Serious AEFI are extremely rare:

38. United Nations High Commissioner for Refugees, Geneva: Third Edition February, 2007  Measles and rubella strategic framework 2021–2030. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO. Measles outbreak guide. Geneva: World Health Organization; 2022. Licence: CC BY-NC-SA 3.0 IGO  Guide for clinical case management and infection prevention and control during a measles outbreak. Geneva: World Health Organization; 2020. Licence:CC BY-NC-SA 3.0 IGO. Sudfeld CR, Navar AM, Halsey NA. Effectiveness of measles vaccination and vitamin A treatment. int J Epidemiol . 2010;39(1):i48–i55 ( https://academic.oup.com/ije/article/39/suppl_1/i48/699532 , accessed 22 January 2020) References

39. Akú Júnior Macuácua Médico GP Mestrando Medicina Tropical Thank you