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

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120

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80001979

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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

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Measles Epidemic Curve by weeks & na-tionality /Jordan/2013

Jordanian Syrians Irakians

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Amman

Mafrak

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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

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100.0

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I.R /1000000

<1 year 1-4 5-9 10-14 15-19 20-24 25-29 >30 years0

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IrakiessyrianJordanian

Measles cases by age group & nationality

Jordanian syrian Irakies0

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70

FemaleMale

Measles cases by gender & nationality

Measles cases by vaccination status & nationality

Jordanian Syrian Irak0

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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%

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60%

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100%

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port

ed A

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Measles Vitamin A

Irbid (n=819) 89.7% 88.0%

Mafraq (n=850) 89.6% 88.1%

Total (n=1669) 89.7% 88.0%

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Estim

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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%

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Age

6m-<60m 91.1%

5y-<10y 92.0%

10y-<15y 85.3%

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* 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 ).

Acknowledgment

• WHO• UNICEF• CDC• UNHCR• IOM• NITAG

Thank you