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Epidemiology of Vaccine Preventable diseases in Iran
Dr Seyed Mohsen ZahraeiCenter for Communicable Disease Control
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Outline
• The mean and importance of surveillance• Surveillance system functionality• Regional targets for Vaccine Preventable
Diseases • Progress towards achieving the targets in Polio,
Measles and Rubella• Challenges and opportunities
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Definition of Surveillance
Disease surveillance is the ongoing systematic collection, analysis and interpretation of data and dissemination of INFORMATION to those who need to know FOR ACTION to be taken
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Surveillance
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• Importance of VPDs surveillance:
– Demonstrate the real effectiveness of the vaccination programme
in reaching its objective, reduction of VPDs: Measles
control/elimination, MNTE, control of diphtheria and pertussis,…..
– Demonstrate the need for intervention: introduction of new
vaccines
• Dangerous if not properly implemented: drawing incorrect conclusion:
– decreasing trend/low estimate of a disease, the programme is
doing fine
– low burden of a disease, the new vaccine is not a priority
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Process & Stages of Surveillance
Notification of suspect case Case investigation & specimen collection Reporting Laboratory testing Integration of field and laboratory data Final case classification Feedback
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Core Surveillance Indicators
Timeliness of reporting Reporting rate Representativeness of reporting
Adequacy of epidemiological investigation Timeliness of notification
Laboratory confirmation Agent detection Specimen transport & lab reporting
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Measles Surveillance in the Elimination Phase
Surveillance priorities: Confirm all cases Detect virus from all outbreaks (chains of transmission)
Surveillance system attributes: Sensitive – identify all suspect cases of measles & rubella Timely – prompt notification, investigation and response Complete -- case investigations, laboratory confirmation &
virus detection
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Surveillance Indicators (1)
Timeliness (& completeness) of reporting Proportion of surveillance units reporting to the national
level on time (Target: >80%)
Used to identify poorly functioning units / districts / governorates / countries
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Surveillance Indicators (2)
Reporting rate Reporting rate of discarded non-measles non-rubella cases
at the national level Target: >2 cases per 100,000 population per year
Representativeness of reporting Proportion of sub-national (province or governorate) units
reporting >2 discarded cases/100,000 pop/yr Combine units, if needed, to achieve >100,000 pop Target: >80%
Used to assess surveillance sensitivity at national & sub-national levels
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Surveillance Indicators (3) Adequacy of investigation
Proportion of all suspected measles & rubella cases with adequate investigation initiated within 48 hours after notification
An adequate investigation includes collection of all relevant data elements from each suspected case
Data elements: Identifiers, residence, place of infection, age, sex rash onset date, specimen collection date, etc.
Target: >80%
Used to assess timeliness & completeness of case investigation (epidemiological component)
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Surveillance Indicators (4) Laboratory confirmation
Proportion of suspected cases with adequate specimen for detecting acute measles or rubella infection collected and tested by a proficient laboratory.
Adequate specimens include serum sample, DBS, or oral fluid, taken within 28 days after rash onset
Cases not tested but confirmed by epi-linkage to a confirmed case of measles, rubella or other communicable disease excluded from denominator
Target: >80% Used to assess completeness of case investigation
(“serological” component)
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Surveillance Indicators (5) Virus detection
Proportion of laboratory-confirmed outbreaks (chains of transmission) with adequate specimens for detecting measles or rubella virus collected and tested in an accredited laboratory.
Adequate specimens include a) throat swabs or urine samples for virus isolation (collected <5 days after rash onset), or b) throat swabs or oral fluid samples for molecular detection (collected <14 days or <21 days, respectively, after rash onset)
Target: >80% Used to assess completeness of case investigation
(virological component)
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Surveillance Indicators (6)
Timeliness of specimen transport Proportion of specimens received at the laboratory <5
days [Target: >80%]
Timeliness of laboratory reporting Proportion of results reported by the laboratory <4 days of
specimen receipt [Target: >80%]
Used to assess timeliness of case investigation (epidemiological & laboratory components)
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SummarySummary
Standardized definitions have been developed for case classification & elimination verification
In the elimination phase, surveillance for measles & rubella needs to be Geographically representative Sensitive Timely Complete
Current indicators are used to assess quality of case investigations & overall surveillance system Targets for indicators (>80%) are minimums
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The Targets: for each country
Soonest possible (for countries that haven’t achieved yet)• Achieve at least 90% DPT3 coverage at national level AND 80% in
every district (target date 2010)• Eliminate MNT soonest possible (target date 2007)By 2012• Eradicate polioBy 2015, • Eliminate measles (regional target)• Reduce HBsAg prevalence to < 1% among <5 years children
(Regional target)• Reduce VPDs morbidity and mortality by 2/3 compared to 2000
(GIVS goal)• Introduce new vaccines (Hib, PCV and Rota) to all countries as soon
as possible (RC58, 2011)
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Poliomyelitis Eradication InitiativeThe End Game
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Poliomyelitis was selected for eradication because :
There is no animal reservoir. There is no chronic carrier state. Poliovirus survives poorly in the
environment. Presence of effective vaccine against the
disease
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The Global Polio Eradication Emergency Action Plan aims to boost vaccination coverage in Nigeria, Pakistan and Afghanistan, the three
remaining polio endemic countries, to levels needed to stop polio transmission.
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Polio-free Status of 21 Countries of EMRO is Maintained
EMRO 09/09/2012
Polio Cases2011September 2012
CountryP1P3P1P3P1P3
Pakistan19623221
Afghanistan8001700
- cVDPV in Yemen 2011 last case Oct 2011
-Continuous cVDPV in Somalia from 2008- 2012 with last case in
23/07/2012
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%of NP AFP cases 6-< 59
months with 3 or more OPV
doses by province in EMR countries,
2012
Source: WHO/UNICEF Estimates of National Immunization Coverage
EMRO 09/09/2012
Routine OPV3 coverage, 2011
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Immunity profile of NP AFP cases 6-59 months in EMR countries, 2012 up to 09/09/12
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Country20052006200720082009201020112012
AFGcVDPV2 (01)cVDPV2 (05)cVDPV 2 (01)
EGYaVDPV2 (Sewage Behira)
iVDPV3 (01)
aVDPV2 (Sewage Behira)
aVDPV 2 (Sewage Behira)
aVDPV 1 Helwan-Cairo
iVDPV1 (01)
iVDPV2 (01)
iVDPV3 (01)
iVDPV2 (01)
IRANiVDPV2 (01)iVDPV2 (01)
iVDPV3 (01)
iVDPV1 + iVDPV2 (01)
iVDPV2 (01)iVDPV2 (02)iVDPV2 (01)
KWTiVDPV3 (01)
IRAQiVDPV2 (01)
MORiVDPV2
Detected in Spain
SAAiVDPV2
SOMVDPV2 (02)cVDPV2 (03)cVDPV2 (07)cVDPV 2 (02)cVDPV2 (09)cVDPV2 (01)
SYRVDPV2 (01)VDPV2 (01)aVDPV 2(01)
SudanaVDPV2 (01)
South Sudan
aVDPV2 (01)aVDPV2 (01)
TUNiVDPV2 (1)iVDPV1 (a)P1 iVDPV (a)
P3 iVDPV? (b)
YEMiVDPV2cVDPV 2 (09)aVDPV2 (01)
aVDPV3 (01)
VDPVs isolated in EMR
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Measles and Rubella Elimination in EMR Countries
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Measles deaths down by 74%Measles deaths
down by 74%
Progress in global measles control, 2000–2010. WER 3 Feb 2012, vol. 87, 5 (pp 45–52) Lancet in press; 2012 IVB model by Simons, Ferrari et al.
Measles cases down by 62%
Measles cases down by 62%
0100,000200,000300,000400,000500,000600,000700,000800,000900,000
2000 2002 2004 2006 2008 2010
AFR AMR EMR EUR SEAR WPR
Reported cases of measles 2000-2011
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Source: Country reports Inadequate surveillance
2,052
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Measles Cases, Incidence and Virus Genotypes, 2009- 2012*
YearMeasles Suspected Cases
Confirmed Measles casesMeasles Incidence/Million
Detected Genotype LabEpi-
LinkedClinical/ Compatible
Total
2009128211871322573.4D4 , H1
2010248925902755347.15D4 , D1
201126411801141351.8D4
201223941544492012.6B3, H1, D4
* *Up to August
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Measles Confirmed Cases, 2009 – 2012*ca
ses
*Display in line graph the distribution of confirmed measles cases by month for 2009 – 2012 up to August
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Map 2011
Geographical Distribution Of Confirmed Measles Cases By Province, 2009 - 2012
Map 2009Map 2009
• Map 2012
• Map 2010
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Confirmed measles Cases ( Lab+Epi-linked ) by age group 2009 - 2012
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Source: Country reports Inadequate/No surveillance
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Suspected
casesNumber of
TestedRubella Positive
Measlespositive
2005 536410116
2006 9437711545
2007 900796521
2008 9728681015
2009 128211599118
2010 2489221222258
2011 247622321518
Total9598844887460
Rubella detected cases based on fever and rash surveillance system, Iran, 2005-2011
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CRS Surveillance in Iran
• Established in 2004, after MR mass campaign.• Accelerated passive surveillance, comprehensive• All hospitals which may admit suspected cases are covered
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CRS suspected Case Definition
• An infant (0-11 months) whose mother had suspected or confirmed history of rubella in pregnancy
• An infant (0-11 months) with heart disease and or
ophthalmic disease and or deafness
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CRS suspected cases by sign
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Summary• Progress
– Well developed PHC network– High immunity level– Robust surveillance system
• Challenges– New reporting sites– Training – Private sector partnership– Need to performance indicators