Factors contributing to measles transmission during an outbreak in Kamwenge District, Western Uganda, April to August 2015

Improving the effectiveness of Field Epidemiology Training Programs: characteristics that facilitated effective response to the COVID-19 pandemic in Uganda

BACKGROUND

The global need for well-trained field epidemiologists has been underscored in the last decade in multiple pandemics, the most recent being COVID-19. Field Epidemiology Training Programs (FETPs) are in-service training programs that improve country capacities to respond to public health emergencies across different levels of the health system. Best practices for FETP implementation have been described previously. The Uganda Public Health Fellowship Program (PHFP), or Advanced-FETP in Uganda, is a two-year fellowship in field epidemiology funded by the U.S. Centers for Disease Control and situated in the Uganda National Institute of Public Health (UNIPH). We describe how specific attributes of the Uganda PHFP that are aligned with best practices enabled substantial contributions to the COVID-19 response in Uganda.

METHODS

We describe the PHFP in Uganda and review examples of how specific program characteristics facilitate integration with Ministry of Health needs and foster a strong response, using COVID-19 pandemic response activities as examples. We describe PHFP activities and outputs before and during the COVID-19 response and offer expert opinions about the impact of the program set-up on these outputs.

RESULTS

Unlike nearly all other Advanced FETPs in Africa, PHFP is delinked from an academic degree-granting program and enrolls only post-Master's-degree fellows. This enables full-time, uninterrupted commitment of academically-trained fellows to public health response. Uganda's PHFP has strong partner support in country, sufficient technical support from program staff, Ministry of Health (MoH), CDC, and partners, and full-time dedicated directorship from a well-respected MoH staff member. The PHFP is physically co-located inside the UNIPH with the emergency operations center (EOC), which provides a direct path for health alerts to be investigated by fellows. It has recognized value within the MoH, which integrates graduates into key MoH and partner positions. During February 2020-September 2021, PHFP fellows and graduates completed 67 major COVID-related projects. PHFP activities during the COVID-19 response were specifically requested by the MoH or by partners, or generated de novo by the program, and were supervised by all partners.

CONCLUSION

Specific attributes of the PHFP enable effective service to the Ministry of Health in Uganda. Among the most important is the enrollment of post-graduate fellows, which leads to a high level of utilization of the program fellows by the Ministry of Health to fulfill real-time needs. Strong leadership and sufficient technical support permitted meaningful program outputs during COVID-19 pandemic response. Ensuring the inclusion of similar characteristics when implementing FETPs elsewhere may allow them to achieve a high level of impact.

Measles outbreak investigation in Aweil East county, South Sudan

During January 2018-June 2020, Aweil East confirmed five measles outbreaks. In March 2020, Aweil East reported twenty measles IgM+ cases. Before this outbreak, Aweil East had confirmed an outbreak in late November 2019. Even after conducting outbreak reactive vaccinations (ORV) in December 2019 and February 2020, measles spread was not interrupted. The nationally supported measles follow-up campaign (MFUC) conducted in late February 2020 was deferred in Aweil East because of the February ORV. We reviewed the measles data collected through passive and active surveillance. A matched case-control study was conducted to evaluate potential exposures. Face-to-face interviews with cases and controls using a semi-structured questionnaire were used to collect demographics, disease, and exposures related data. A total of 687 cases with eight deaths; attack and case fatality rate of 123/100,000 population and 1.16%, respectively. Among the cases, 51.8% were male, the median age was four years, and 59% of cases ≥9 months were unvaccinated. Eighty point six percent (80.6%) of cases reported after the February ORV were unvaccinated. The outbreak peaked in late March 2020. Unvaccinated persons had higher odds of getting measles (adjusted odds ratio (AOR)=8.569; 95% CI [1.41- 53.4], p=0.02). Non exposed persons had a lower odd of getting measles (AOR=0.114; 95% CI [0.02-0.61], p=0.011). During 2018-2019, the accumulated number of unvaccinated children (18,587) is more than a birth cohort of the county. Persistent low routine vaccination is the most critical driver of the measles outbreaks. Low-quality ORV and the intermediate population density are secondary drivers of the outbreaks.

Descriptive epidemiology of measles cases in Bauchi State, 2013-2018

BACKGROUND

Measles accounts for high morbidity and mortality in children, especially in developing countries. In 2017, about 11,190 measles cases were recorded in Nigeria, including Bauchi State. The aim of this study was to describe the trend and burden of measles in Bauchi State, Nigeria.

METHOD

We analyzed secondary data of measles cases extracted from the Measles Surveillance data system in Bauchi State from January 2013 to June 2018. The variables extracted included age, sex, doses of vaccination, case location and outcome. Data were analyzed using descriptive statistics, logistic regression, and multiplicative time series model (α = 0.05).

RESULTS

A total of 4935 suspected measles cases with an average annual incidence rate of 15.3 per 100,000 population and 57 deaths (Case Fatality Rate, CFR: 1.15%) were reported. Among the reported cases, 294 (6%;) were laboratory-confirmed, while clinically compatible and epi-linked cases were 402 (8%) and 3879 (70%), respectively. Of the 4935 measles cases, 2576 (52%) were males, 440 (9%) were under 1 year of age, and 3289 (67%) were between 1 and 4 years. The average annual incidence rate among the 1-4 year age-group was 70.3 per 100,000 population. The incidence rate was lowest in 2018 with 2.1 per 100,000 and highest in 2015 with 26.2 per 100,000 population. The measles cases variation index per quarter was highest in quarter 1 (198.86), followed by quarter 2 (62.21) and least in quarter 4 (10.37) of every year. Only 889 (18%) of the measles cases received at least one dose of measles vaccine, 2701 (54.7%) had no history of measles vaccination while 1346 (27.3%) had unknown vaccination status. The fatality of measles in Bauchi State were significantly associated with being under 5 years (AOR = 5.58; 95%CI: 2.19-14.22) and not having at least a dose of MCV (OR = 7.14; 95%CI: 3.70-14.29).

CONCLUSION

Measles burden remains high in Bauchi State despite a decrease in its incidence over the study years. Most of the cases occurred in the first quarter of every year. Improved routine measles surveillance for prompt case management could reduce the burden of the disease in Bauchi State.

Risk factors for measles outbreak in Ataq and Habban districts, Shabwah governorate, Yemen, February to May 2018

BACKGROUND

Recent conflict and war in Yemen lead to collapse of the health system, decrease of immunization coverage and spread of many outbreaks. On May 22, 2018, the surveillance officer in Shabwah governorate reported an increased number of suspected measles. On May 24, 2018, a team from Yemen-Field Epidemiology Training Program was sent to investigate. The aims were to describe the outbreak, determine the risk factors for measles infection and recommend control measures.

METHODOLOGY

A descriptive followed by case-control study design (1:2 ratio) were performed. National Measles Surveillance Program case definition and predesigned questionnaire were used to collect data from 73 cases and 146 controls. Attack rate (AR), adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) were calculated. P value < 0.05 was considered as the cut point for significant. Epi info version 7.2 was used.

RESULTS

A total of 73 suspected cases were found. Almost 53% were from Habban district, 63% were males and 56% were among age group < 5 years. The overall AR was 82/100,000 population. Measles was significantly associated with contact with case (aOR = 27.3, 95% CI:1.3-551.7), malnourished children aged 6-60 months (aOR = 24.9, 95% CI;1.9-329.6) and unvaccinated children (aOR = 17.2, 95% CI:2.9-100.7). The six collected blood samples found to be positive for measles IgM.

CONCLUSIONS

Measles outbreak in Ataq and Habban districts was confirmed. Contact with measles cases, malnutrition and un-vaccination were the potential contributing factors of measles outbreak in Shabwah governorate. An urgent vaccination campaign with health education interventions are highly recommended. Reactivation of the outreach immunization services and strengthening surveillance and response systems are top priority to take place at district and governorate levels.

The economic burden of measles in children under five in Uganda

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Measles costed over $135,627 in societal costs for 2018, incl. $59,357 to households.

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Ugandan caregivers faced $44 in economic costs incl. $23 in out-of-pocket payments.

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Measles deepens the inequalities in access to healthcare in the population.

Background

There is very limited evidence about the economic cost of measles in low-income countries. We estimated the cost of treating measles in Uganda from a societal perspective.

Methods

We conducted an incidence-based cost-of-illness study in Uganda. We surveyed the facility staff, recording hospital-related expenditures for measles patients. We interviewed caregivers of children with measles at 48 selected healthcare facilities. We conducted phone interviews with caregivers 7–14 days post-discharge to capture additional out-of-pocket expenses and time costs.

Results

From a societal perspective, a hospitalized and an ambulatory episode of measles cost 2018 US$ 60 and $15, respectively. The government spent on average $12 and $5 per hospitalized and ambulatory episode of measles. Including both public and private facilities, caregivers incurred approximately $44 in economic costs, including $23 in out-of-pocket expenses. In 2018, 2614 cases of measles were confirmed, resulting in $135,627 in societal costs, including $59,357 in economic costs to Ugandan households.

Conclusion

This cost-of-illness study is the first to use empirical methods to quantify the economic burden of measles in a low-income country. Information related to the cost of treating measles is important for guiding decisions related to changes in measles control and prevention.

Measles outbreak amplified in a pediatric ward: Lyantonde District, Uganda, August 2017

Background

Measles is a highly infectious viral disease. In August 2017, Lyantonde District, Uganda reported a measles outbreak to Uganda Ministry of Health. We investigated the outbreak to assess the scope, factors facilitating transmission, and recommend control measures.

Methods

We defined a probable case as sudden onset of fever and generalized rash in a resident of Lyantonde, Lwengo, or Rakai Districts from 1 June-30 September 2017, plus ≥1 of the following: coryza, conjunctivitis, or cough. A confirmed case was a probable case with serum positivity of measles-specific IgM. We conducted a neighborhood- and age-matched case-control study to identified exposure factors, and used conditional logistic regression to analyze the data. We estimated vaccine effectiveness and vaccination coverage.

Results

We identified 81 cases (75 probable, 6 confirmed); 4 patients (4.9%) died. In the case-control study, 47% of case-patients and 2.3% of controls were hospitalized at Lyantonde Hospital pediatric department for non-measles conditions 7–21 days before case-patient’s onset (OR_adj = 34, 95%CI: 5.1–225). Estimated vaccine effectiveness was 95% (95%CI: 75–99%) and vaccination coverage was 76% (95%CI: 68–82%). During the outbreak, an “isolation” ward was established inside the general pediatric ward where there was mixing of both measles and non-measles patients.

Conclusions

This outbreak was amplified by nosocomial transmission and facilitated by low vaccination coverage. We recommended moving the isolation ward outside of the building, supplemental vaccination, and vaccinating pediatric patients during measles outbreaks.

The effect of time since measles vaccination and age at first dose on measles vaccine effectiveness - A systematic review

BACKGROUND

In settings where measles has been eliminated, vaccine-derived immunity may in theory wane more rapidly due to a lack of immune boosting by circulating measles virus. We aimed to assess whether measles vaccine effectiveness (VE) waned over time, and if so, whether differentially in measles-eliminated and measles-endemic settings.

METHODS

We performed a systematic literature review of studies that reported VE and time since vaccination with measles-containing vaccine (MCV). We extracted information on case definition (clinical symptoms and/or laboratory diagnosis), method of vaccination status ascertainment (medical record or vaccine registry), as well as any biases which may have arisen from cold chain issues and a lack of an age at first dose of MCV. We then used linear regression to evaluate VE as a function of age at first dose of MCV and time since MCV.

RESULTS

After screening 14,782 citations, we identified three full-text articles from measles-eliminated settings and 33 articles from measles-endemic settings. In elimination settings, two-dose VE estimates increased as age at first dose of MCV increased and decreased as time since MCV increased; however, the small number of studies available limited interpretation. In measles-endemic settings, one-dose VE increased by 1.5% (95% CI 0.5, 2.5) for every month increase in age at first dose of MCV. We found no evidence of waning VE in endemic settings.

CONCLUSIONS

The paucity of data from measles-eliminated settings indicates that additional studies and approaches (such as studies using proxies including laboratory correlates of protection) are needed to answer the question of whether VE in measles-eliminated settings wanes. Age at first dose of MCV was the most important factor in determining VE. More VE studies need to be conducted in elimination settings, and standards should be developed for information collected and reported in such studies.

Observational study of a new strategy and management policy for measles prevention in medical personnel in a hospital setting

Background

At the end of March 2018, a clustered outbreak of measles associated with health care workers occurred in northern Taiwan. Prior to this study, the policy for measles vaccination for physicians and nurses in MacKay Memorial Hospital, Taiwan was encouragement of vaccination in medical personnel working in the emergency room or other high risk divisions without prior testing for measles antibody, and vaccination coverage was only 85.3%. It was important to urgently formulate a new strategy to achieve zero tolerance for intra-hospital transmission and epidemic prevention. This study aimed to explore the effectiveness of a new strategy for the prevention of an outbreak of measles.

Methods

This study was conducted from April 23, 2018 to May 22, 2018 in the MacKay Memorial Hospital, a medical center and tertiary teaching hospital with 2200 beds in northern Taiwan. First-line medical personnel in the hospital underwent a free screening for measles antibody as a new strategy for measles outbreak prevention. Susceptible medical personnel were advised to receive measles vaccination.

Results

A total of 719 first-line medical personnel were enrolled for the general survey. Measles seropositivity was 76.1% (287/377) in the generation born after 1978 (vaccinated), and 96.5% (330/342) in the generation born before 1978 (p < 0.001), while the overall seropositivity was 85.8% (617/719). Vaccination coverage of susceptible personnel under the new strategy reached 86.3% in the first month (88/102) following the survey. At the end of the first month after implementation of the new strategy, 98.1% of the medical personnel were seropositive or revaccinated, and reached 99.4% at the end of the second month.

Conclusions

In this study, rapid, free antibody screening during a measles outbreak and subsequent vaccination of those susceptible resulted in most of the first-line medical personnel being seropositive or revaccinated. The new strategy was effective, time saving, used little manpower, and of low cost. Screening for measles antibody free of charge followed by vaccination of seronegative medical personnel can be regarded as an effective health management strategy to reduce and prevent the spread of measles infection.

Assessing measles vaccine failure in Tianjin, China

Despite increasing global measles vaccination coverage, progress toward measles elimination has slowed in recent years. In China, children receive a measles-containing vaccine (MCV) at 8 months, 18-24 months, and some urban areas offer a third dose at age 4-6 years. However, substantial measles cases in Tianjin, China, occur among individuals who have received multiple MCV doses. This study describes the vaccination history of measles cases 8 months - 19 years old. Data came from measles cases in Tianjin's reportable disease surveillance system (2009-2013), and from a case control study (2011-2015). Twenty-nine percent of those in the surveillance dataset and 54.4% of those in the case series received at least one dose of MCV. The minimum and median time-to-diagnosis since vaccination revealed an increase in time since vaccination for incremental doses. Considerable measles cases in Tianjin occur in vaccinated children, and further research is needed to understand the reasons for vaccine failure.

Epidemiologic profile of measles in Central African Republic: A nine year survey, 2007-2015

INTRODUCTION

Measles remains a major public health problem in many developing countries in which vaccination coverage is poor, as is the case in the Central African Republic (CAR). At the beginning of the 2000s, a surveillance system was established in the country, and samples from suspected cases are regularly tested in the laboratory for serological confirmation. Since 2007, when case-by-case monitoring with standardized laboratory databases and monitoring, was set up, no assessment have been performed. Therfore, 9 years later it seemed appropriate to make a first assessment. The aim of the study reported here was to describe the epidemiology of measles in the CAR on the basis of surveillance and laboratory data.

METHOD

A descriptive retrospective study was conducted, based on the databases of the measles surveillance programme and of the Institut Pasteur laboratory in Bangui during the period 2007-2015.

RESULTS

During this study period, the surveillance programme notified 3767 cases. Of these, 2795 (75%) were sent for laboratory confirmation, and 24.6% (687/2795) were confirmed serologically. Of the 1797 cases of measles declared during this period by the surveillance programme, 1110 (61.8%) were confirmed clinically or by epidemiological linkage. The majority of confirmed cases (83.7%; 575/687) occurred in children under 10 years, over half of whom (44.2%; 304/687) were aged 1-4 years. Epidemics occurred regularly between 2011 and 2015, with > 10% of laboratory-confirmed cases. The rate of laboratory investigation was < 80% between 2011 and 2013 but nearly 100% in the other years.

CONCLUSION

Measles remains a common, endemic illness in the CAR. Improved detection will require better measles surveillance, increased vaccination coverage, revision of the investigation forms to include the WHO case definition and training of the health personnel involved in case-finding in the field.

Effect of Schistosoma mansoni infection and its treatment on antibody responses to measles catch-up immunisation in pre-school children: A randomised trial

BACKGROUND

Schistosoma infection is associated with immune modulation that can influence responses to non-schistosome antigens. Vaccine responses may be impaired in S. mansoni-infected individuals. We investigated effects of S. mansoni infection on responses to childhood measles catch-up immunisation and of praziquantel treatment on this outcome in a randomised trial.

METHODOLOGY

The Immune Modulation and Childhood Immunisation (IMoChI) study was based in Entebbe, Uganda. Children aged 3-5 years (193 S. mansoni-infected and 61 uninfected) were enrolled. Infected children were randomised in a 1:1:1 ratio to receive praziquantel 2 weeks before, at time of, or 1 week after, measles catch-up immunisation. Plasma anti-measles IgG was measured at enrolment, 1 week and 24 weeks after measles immunisation. Primary outcomes were IgG levels and percentage of participants with levels considered protective against measles.

RESULTS

Anti-measles IgG levels increased following immunisation, but at 1 week post-immunisation S. mansoni-infected, compared to uninfected, children had lower levels of anti-measles IgG (adjusted geometric mean ratio (aGMR) 0.4 [95% CI 0.2-0.7]) and the percentage with protective antibody levels was also lower (adjusted odds ratio 0.1 [0-0.9]). Among S. mansoni-infected children, anti-measles IgG one week post-immunisation was higher among those treated with praziquantel than among those who were not yet treated (treatment before immunisation, aGMR 2.3 [1.5-4.8]; treatment at immunisation aGMR 1.8 [1.1-3.5]). At 24 weeks post-immunisation, IgG levels did not differ between the trial groups, but tended to be lower among previously-infected children who were still S mansoni stool-positive than among those who became stool-negative.

CONCLUSIONS AND SIGNIFICANCE

Our findings suggest that S. mansoni infection among pre-school children is associated with a reduced antibody response to catch-up measles immunisation, and that praziquantel treatment improves the response. S. mansoni infection may contribute to impaired vaccine responses in endemic populations; effective schistosomiasis control may be beneficial for vaccine efficacy. This should be further explored.

TRIAL REGISTRATION

ISRCTN87107592.

Investigating an outbreak of measles in Kamwenge District, Uganda, July 2015

Globalization has opened many fronts for disease outbreaks because of the quick movement of people and porous borders around the world. The emergence of zoonotic diseases and other communicable diseases highlights the need for implementation of the Global Health Security Agenda packages if countries are to achieve compliance with International Health Regulations (IHR 2005). Health workforce development is one of the critical components that must be addressed with utmost urgency if gaps in early disease detection and response are to be addressed. In this regard, this case study is based on a measles outbreak investigation in Uganda simulating a real-life outbreak investigation by field epidemiologists and seeks to demonstrate the principles of applied epidemiology outlining the critical steps in outbreak investigations and generation of evidence for decision making. It aims to shore up the health workforce capacity by providing practical training for field epidemiology students and professionals that builds their skills in outbreak investigation. This case study can be completed in less than three hours.