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EMRO Technical Publications Series 36

Field guidelines for


surveillance of measles,
rubella and congenital
rubella syndrome
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Field guidelines for surveillance of measles, rubella and congenital rubella syndrome / World Health
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© World Health Organization 2011


All rights reserved.
The designations employed and the presentation of the material in this publication do not imply the expression of
any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country,
territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted
lines on maps represent approximate border lines for which there may not yet be full agreement.
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or recommended by the World Health Organization in preference to others of a similar nature that are not
mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital
letters.
All reasonable precautions have been taken by the World Health Organization to verify the information contained
in this publication. However, the published material is being distributed without warranty of any kind, either
expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no
event shall the World Health Organization be liable for damages arising from its use.
Publications of the World Health Organization can be obtained from Distribution and Sales, World Health
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Contents
Foreword .............................................................................................................. 5
Preface.................................................................................................................. 7
Acknowledgements............................................................................................. 8
1. Introduction ..................................................................................................... 9
2.The diseases ..................................................................................................... 9
 0HDVOHV.......................................................................................................................................................
2.2 Rubella ........................................................................................................................................................
 &RQJHQLWDOUXEHOODV\QGURPH ................................................................................................................2
 0HDVOHVUXEHOODDQG&56VXUYHLOODQFHREMHFWLYHV .............................................................................2
 0HDVOHVVXUYHLOODQFHREMHFWLYHV.............................................................................................................
 5XEHOOD&56VXUYHLOODQFHREMHFWLYHV ....................................................................................................

4. Establishing and strengthening an integrated measles/rubella/CRS


surveillance system ............................................................................................ 13
 *HQHUDOSULQFLSOHV....................................................................................................................................
 &DVHGHÀQLWLRQV........................................................................................................................................
 5HSRUWLQJVLWHV...........................................................................................................................................

5. Surveillance activities and procedures for measles, rubella and CRS ....... 18
 +HDOWKIDFLOLWLHV...........................................................................................................................................
 'LVWULFWV.......................................................................................................................................................2
 3URYLQFHV.....................................................................................................................................................2
 1DWLRQDOOHYHO .............................................................................................................................................2

6. Investigating and managing measles, rubella and CRS cases...................... 22


 0HDVOHVFDVHLQYHVWLJDWLRQ .......................................................................................................................2
 0HDVOHVFDVHPDQDJHPHQW.......................................................................................................................2
7. Outbreak investigations and control for measles and rubella .................... 25
 0HDVOHVRXWEUHDNLQYHVWLJDWLRQ ..............................................................................................................2
 5XEHOOD&56RXWEUHDNLQYHVWLJDWLRQ......................................................................................................
8. Laboratory support in measles and rubella surveillance ............................ 32
 0HDVOHVUXEHOODVHURORJ\..........................................................................................................................2
 9LUDOGHWHFWLRQLVRODWLRQJHQRW\SLQJ .....................................................................................................
 0HDVOHVUXEHOODODERUDWRU\QHWZRUN.....................................................................................................
 $OWHUQDWLYHVDPSOLQJWHFKQLTXHV ............................................................................................................

9. Surveillance monitoring and feedback.......................................................... 35


 6XUYHLOODQFHSHUIRUPDQFHLQGLFDWRUVIRUFRXQWULHVZLWKHOLPLQDWLRQJRDO....................................
 0HDVXUHVRISURJUHVVWRZDUGVPHDVOHVHOLPLQDWLRQ..........................................................................
 )HHGEDFN .....................................................................................................................................................

References............................................................................................................ 39
Annexes ............................................................................................................... 41
In the name of God, the Compassionate, the Merciful

Foreword
Great progress has been made toward measles elimination in the Eastern Mediterranean Region
since 1997 when the WHO Regional Committee for the Eastern Mediterranean passed a resolution
(EM/RC44/R.6) to eliminate measles by 2010. This progress has been achieved thanks to the
successful implementation of measles elimination strategies in the Region, particularly the high
attainment of measles vaccine coverage and the implementation of a laboratory-supported measles
case-based surveillance system in most countries.
Countries within the Region are at different stages of elimination. Some countries are still
experiencing a high burden of disease and measles surveillance remains suboptimal. Other
countries appear close to elimination, however surveillance systems are not up to the standards
of elimination. Therefore, as most performance indicator targets are still not being met, measles
elimination cannot be validated. There is an urgent need for a well-performing measles surveillance
system to assess the burden of the disease and to measure the progress towards measles elimination
in the Region.
The WHO Regional Office for the Eastern Mediterranean, in collaboration with other partners,
particularly the US Centers for Disease Control and Prevention (CDC), Atlanta, has developed
these guidelines to help establish high-quality measles, rubella and congenital rubella syndrome
(CRS) surveillance systems. These guidelines provide practitioners in the field with the tools to
identify, report and investigate cases of measles, rubella and congenital rubella syndrome. They
also provide information on laboratory testing, identifying measles and rubella suspected cases,
analysing data and monitoring the performance of the surveillance system.
It is hoped that, through the use of these guidelines, better information on measles and rubella can
be obtained, which, in turn, will improve the performance of prevention programmes and reduce
the incidence of morbidity and mortality due to measles and rubella.

Hussein A. Gezairy MD FRCS


WHO Regional Director for the Eastern Mediterranean

5
Preface
One of the strategies to reduce measles mortality is to enhance the surveillance of measles and
rubella and integrate epidemiological and laboratory information. Since 2006, 19 countries of the
Eastern Mediterranean Region have conducted case-based surveillance and a regional laboratory
network has been established in all 22 countries, including two regional reference laboratories–
one in Oman and the other in Tunisia. However, in most countries, the surveillance system for
measles, rubella and congenital rubella syndrome (CRS) is not up to the same standard as the
surveillance system for measles.
In 2006, the regional measles technical advisory group recommended that the Regional Office
develop guidelines for the surveillance of measles, rubella and CRS. An extensive review of the
literature was conducted to ensure that the guidelines were supported by all available evidence on
the methods used to design and implement these surveillance systems. The review included measles
surveillance guidelines already developed by the World Health Organization and the Pan American
Health Organization (PAHO), WHO position papers on measles and rubella and guidelines and
articles on the progress towards measles elimination produced by Centres for Disease Control and
Prevention, Atlanta, USA. The first draft of these guidelines was reviewed by staff of the vaccine
preventable diseases and immunization programme of the Regional Office and then by staff of the
Global Immunization Division, Centres for Disease Control and Prevention. The document was
also shared with country managers of the Expanded Programme on Immunization and surveillance
and laboratory staff of all countries in the Region. In 2008, the guidelines were further reviewed
during an intercountry meeting on measles held in the United Arab Emirates and by members
of the regional measles/rubella technical advisory group. Finally, the document was reviewed
by the surveillance officer focal point for measles at WHO headquarters. All steps have been
taken to identify and manage any circumstances that could give rise to a conflict of interest. The
development process was reviewed and approved by the WHO Guidelines Review Committee.
These field guidelines for the surveillance of measles, rubella and CRS are to be used as technical
resource material in developing comprehensive standard operating procedures for measles, rubella
and CRS surveillance. The largest part of these guidelines is devoted to developing a surveillance
system for cases of measles, rubella and CRS, including case investigation, outbreak response,
laboratory procedures for measles and rubella testing and surveillance monitoring and feedback.
This publication is primarily intended for use by surveillance and national immunization managers
and their staff, but many other health professionals and technical staff working in surveillance,
immunization and laboratories at the country level will find it useful in improving measles, rubella
and CRS surveillance. It can be used at various levels of the health care system and by all countries.
Countries may need to adapt these guidelines to their local situations. It will provide information
to relevant staff on how to comply with the requirements needed in order to ensure a well
performing measles/surveillance system that is able to validate measles and rubella elimination.
This is the first edition of the Field guidelines for the surveillance of measles, rubella and congenital rubella
syndrome developed by the Regional Office for the Eastern Mediterranean. Comments, suggestions
and recommendations from users of these guidelines are welcome. The elimination of measles in
general, and surveillance in particular, are part of an evolving and dynamic process, and hence, it
is expected that the guidelines will be updated as needed.

7
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

Acknowledgements
This publication is the product of contributions by several individuals. The publication was written
by Boubker Naouri, WHO Regional Office for the Eastern Mediterranean, Egypt. The development
process was reviewed and approved by the WHO Guidelines Review Committee. The draft was
reviewed by Susan Reef, Amra Uzicanan and James Alexander (Centres for Disease Control
and Prevention, Global Immunization Division, United States of America), Alya Dabbagh and
David Featherstone (Immunization, Vaccines and Biologicals, WHO headquarters, Switzerland),
Hinda Ahmed and Raef Bekhit (Vaccine Preventable Diseases, WHO Regional Office for the
Eastern Mediterranean, Egypt). Reviewers also included all EPI managers, surveillance officers
and laboratory staff in the WHO Eastern Mediterranean Region.

8
Introduction

Since then, many countries have implemented


1. Introduction measles elimination strategies, have been
Measles, rubella and congenital rubella working towards the elimination of the measles
syndrome (CRS) remain important preventable virus and have elected to accelerate rubella
causes of infectious disease morbidity and control/elimination.
mortality. Measles remains a leading cause
One of the strategies for eliminating measles
of death among young children, despite the
is to enhance measles and rubella surveillance
availability of a safe and effective vaccine since
through integration of epidemiological and
the early 1960s. In 2007, the latest year for
laboratory information. As the number of
which figures are available (1), globally, an
cases of measles declines, the importance of
estimated 197 000 people died from measles,
surveillance will become even greater, to
most of whom were children. In the WHO
identify and aggressively respond to cases
Eastern Mediterranean Region, 15 670 cases
and outbreaks. It will become increasingly
of measles were reported in 2007 compared
crucial that all suspected cases of measles are
to 38 592 in 2000 (2). An estimated 10 000
reported, using surveillance for febrile rash
measles deaths1 occurred in 2007, compared
illnesses, and that samples from sporadic cases
with 106 000 in 2000, representing a 95%
decrease (3). Thus, the goal of the Global are submitted for full laboratory investigation.
Immunization and Vaccination Strategy Specific performance indicators have been
(GIVS) of reducing measles mortality by 95% developed to regularly monitor the measles/
by 2010 was reached three years earlier in the rubella surveillance system.
Region. However, the number of measles cases
reported to the WHO Regional Office for
the Eastern Mediterranean does not represent
2. The diseases
the true number of cases as some countries
2.1 Measles
(Morocco, Pakistan and Somalia) have not yet
developed a nationwide case-based measles  7KHRUJDQLVP
surveillance system.
Measles is an acute illness caused by a virus
In 2006, globally, 251 311 cases of rubella and of the genus Morbillivirus (a member of the
191 cases of CRS were reported (2007 data Paramyxovirus family); humans are the only
not available). During the same year, 3685 reservoir.
rubella cases were reported to the Regional
Office. However, only 10 countries2 in the  7UDQVPLVVLRQ
Region have developed surveillance systems Transmission is primarily person-to-person via
to monitor CRS cases. In 2007, these 10 aerosolized respiratory droplets or by direct
countries reported 23 cases of CRS to the contact (5). Measles is highly infectious and
Regional Office. the disease spreads easily in areas where infants
and children gather, for example, in health care
In 1997, the Member States of the Region
centres and schools. Individuals with measles
resolved to eliminate measles by 2010 (4).
are infectious from 2–4 days before until 4
days after rash onset. Conditions such as high
1
The number of deaths is estimated by a model, and the birth rates, overcrowding and the influx of
reported number of cases likely reflects gross under-reporting
of measles, which explains the apparent discrepancy between large numbers of susceptible children from
the reported number of cases and estimated number of deaths.
2
Bahrain, Egypt, Jordan, Lebanon, Morocco, Oman, occupied
rural areas can facilitate measles transmission.
Palestinian territory, Qatar, Saudi Arabia, Syrian Arab Republic. A small percentage of susceptible individuals

9
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

are sufficient to maintain virus circulation in malnutrition, convulsions and brain damage.
populations of a few hundred thousand. In Unless managed early and aggressively, these
areas with tropical climates, most cases of complications may lead to death within the
measles occur during the dry season, whereas first month after rash onset. The case-fatality
in areas with temperate climates, the incidence rate from measles is estimated to be 3%–5%
peaks during late winter and early spring (5). in developing countries but may reach more
than 10% during epidemics in certain settings.
 &OLQLFDOIHDWXUHV Malnutrition and infection with human
After an incubation period of approximately immunodeficiency virus (HIV) are risk factors
10–14 days (range 8–15 days), from exposure for complications and mortality.
to onset of rash, prodromal symptoms of
fever, malaise, cough, coryza (runny nose) and  ,PPXQLW\
conjunctivitis appear in non-immune persons Measles-specific immunoglobulin M (IgM)
exposed to the virus. antibodies are detectable within 4 days after
The rash appears behind the ears and on the onset of the rash and can persist for up to 4–12
face, accompanied by a high fever. Fever can be weeks. Natural infection produces lifelong
as high as 40.6°C (105°F). The rash is maculo- immunity. Infants born to mothers who have
papular, made up of large, blotchy red spots either had measles or been vaccinated are
(macules are circumscribed areas of change in protected by trans-placental acquired maternal
normal skin colour, with no skin elevation or antibodies. The protection from this passive
depression; they may be of any size). The rash immunity lasts 6 to 9 months on average (5).
typically spreads from the head to the trunk
and then extremities, lasts 3–7 days, and may  0HDVOHVYDFFLQHV
be followed by a fine desquamation. Koplik Measles vaccines contain live, attenuated
spots may occur on the buccal mucosa shortly virus. Following vaccination, the long-term
after the onset of rash and for about 1–2 days persistence of neutralizing measles antibodies
afterwards. (26–33 years) and long-lasting protection
against measles have been demonstrated
A modified form of measles, with generally mild
by several investigators. However, it is not
symptoms, may occur in infants who still have
definitively known whether a single dose of
partial protection from maternal antibodies
measles vaccine, without natural boosting
and occasionally in persons who received only
by recurrent measles exposure, will result in
partial protection from the vaccine.
lifelong protection. Studies using IgG avidity
measurements to separate primary vaccination
 'LIIHUHQWLDOGLDJQRVLV
failures from secondary vaccination failures
Infections with a number of other viruses can
suggest that secondary failures may occur at
present with a rash resembling that of measles,
least occasionally (5,6,7).
including rubella virus, parvovirus, enterovirus,
adenovirus and human herpesvirus 6. Measles-containing vaccine can be safely
and effectively administered to children
 &RPSOLFDWLRQV with mild acute illnesses, such as low-grade
Complications of measles include otitis fever, diarrhoea and upper respiratory tract
media, pneumonia, diarrhoea, febrile seizure, infections. However, severely-ill children
blindness and encephalitis. Less common with high fever should not be vaccinated
complications include protein energy until they have recovered. People who

10
The diseases

have experienced an anaphylactic or severe 2.2.2 Transmission


hypersensitivity reaction to a previous dose of The rubella virus, while less contagious
measles/mumps/rubella (MMR) vaccine or its than that of measles, is also transmitted by
component vaccines or who have experienced respiratory droplets and by direct contact
an anaphylactic reaction to neomycin, gelatine with the nasal and throat secretions of infected
or another component of the vaccine should persons. While individuals with rubella may
not be vaccinated (5). In countries where HIV shed virus from 7 days before to 14 days after
infection is prevalent, infants and children the onset of rash, 25% to 50% of infections are
should be immunized with the EPI antigens asymptomatic.
according to standard schedules. However,
measles vaccine is contraindicated in people  &OLQLFDOIHDWXUHV
who are severely immunocompromised due Rubella is a common cause of maculopapular
to congenital disease; severe HIV infection; rash illness with low-grade fever. Symptoms in
advanced leukaemia or lymphoma; serious children and adults are often mild, and children
malignant disease; treatment with high-dose often do not have fever. In addition to fever
steroids, alkylating agents or antimetabolites; and rash, individuals with rubella frequently
or who receive immunosuppressive therapeutic have lymphadenopathy, and up to 60% of adult
radiation (5). As vaccinated persons do not women with rubella have joint symptoms. Up
transmit vaccine virus, the risk to these to 50% of rubella infections are subclinical or
patients of being exposed to measles may be asymptomatic.
reduced by vaccinating their direct susceptible
contacts. Rubella-containing vaccine should  'LIIHUHQWLDOGLDJQRVLV
not be administered to pregnant women (5). Other causes of rash illness with fever include
This contraindication is based on theoretical measles, dengue, parvovirus B19, human
reasons, as there is currently no evidence to herpesvirus 6, Ross River virus, Chikungunya
suggest that children born to pregnant women virus, enteroviruses, adenoviruses and Streptococcus
who received measles or MMR vaccines during group A (beta hemolytic).
pregnancy are adversely affected (5).
 &RPSOLFDWLRQV
 7UHDWPHQW
Rubella has few complications unless the virus
There is currently no specific treatment for is contracted by a susceptible pregnant woman.
measles infection. Administration of vitamin A primary rubella infection (i.e. infection of
A to children with measles has been shown to a susceptible woman) during pregnancy may
decrease both the severity of disease and the result in spontaneous abortion, stillbirth or
case-fatality rate, and WHO recommends that fetal death; an infant born with CRS; an infant
vitamin A be administered to all children with born with congenital rubella infection (CRI)
acute measles (8). Case management of measles without congenital defects; or birth of a normal
cases is discussed in detail in Section 6.2. infant.

2.2 Rubella  ,PPXQLW\


Rubella-specific IgM antibody usually appears
 7KHRUJDQLVP within 4 days after onset of the rash and can
Rubella is an acute illness caused by a virus of persist for up to 4–12 weeks. Rubella-specific
the family Togaviridae. IgG antibody begins to rise after the onset
of the rash, peaks about 4 weeks later, and

11
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

generally lasts for life; it is a long-term marker 2.3 Congenital rubella


of previous rubella infection. Natural infection syndrome
produces lifelong immunity.
A rubella-infected fetus carried to term may
 5XEHOODYDFFLQH be born with CRS. Some defects associated
The rubella vaccine widely used around with CRS may be recognizable at birth, while
the world is based on the live attenuated others are detected months or even years later.
RA27/3 strain of rubella virus. Protective CRS manifestations may be transient (e.g.
antibodies against rubella develop in >95% purpura), permanent structural manifestations
of vaccinees 21–28 days after vaccination. (e.g. deafness, central nervous system defects,
One dose of rubella vaccine probably confers congenital heart disease, cataract), or late-
lifelong immunity in more than 95% of people emerging conditions (e.g. diabetes mellitus).
immunized. At birth, the sera of infants with CRS contain
The primary purpose of rubella vaccination maternally derived rubella-specific IgG
is to prevent the occurrence of CRS. Two antibodies, as well as IgG and IgM antibodies
approaches are recommended for CRS synthesized by the fetus. In contrast, only
prevention (9), which are: maternal rubella-specific IgG is found in the
sera of normal infants born to women who are
‡ prevention of CRS only through
immune to rubella. Infants with CRS may shed
immunization of adolescent girls and/or
rubella virus from body secretions for up to 27
women of childbearing age.
months, although most infants stop shedding
‡ elimination of rubella, as well as CRS,
by one year of age. Infants who shed rubella
through universal routine vaccination of
virus are infectious, and rubella outbreaks have
infants with/without mass campaigns,
occurred among health care workers caring for
surveillance and ensuring immunity in
infants with CRS.
women of childbearing age.
Rubella vaccine is very safe. Most adverse
reactions reported following MMR vaccination 3. Measles, rubella
(such as fever and rash) are attributable to
the measles component. The most common and CRS surveillance
complaints following vaccination are fever, objectives
lymphadenopathy and arthralgia. Rubella
vaccination should be avoided in pregnancy Surveillance is the ongoing systematic
because of the theoretical, but never collection, analysis and interpretation of
demonstrated, teratogenic risk (9). outcome-specific data for use in planning,
implementing and evaluating public health
 7UHDWPHQW practice. The primary surveillance goal is to
There is no specific treatment for rubella or for detect and investigate all suspected measles
CRS. Patients with rubella should drink plenty cases, including imported ones, and to
of fluids and may take medication to reduce implement activities which prevent or limit
mild fever. Infants with CRS should be treated secondary transmission (10). Besides the rapid
for their specific problems. detection of cases, a surveillance system that
maintains a satisfactory record over several
years will be crucial to the eventual validation
of measles elimination.

12
Establishing/strengthening surveillance systems

3.1 Measles surveillance 3.2 Rubella/CRS surveillance


objectives objectives
Every measles case could potentially spark Case-based surveillance of rubella is essentially
an outbreak, especially if under-vaccinated conducted in exactly the same way as measles.
groups are exposed. Surveillance and prompt The objectives of rubella/CRS surveillance
investigation of cases and contacts contribute are:
to halting the spread of disease. Information
‡ identifying populations at risk and guiding
obtained through surveillance is also used to
vaccination strategies;
assess progress towards disease elimination
‡ determining where the virus is circulating;
goals. Surveillance data are used to characterize ‡ detecting cases in a timely manner in
persons, groups or areas in which additional order to carry-out outbreak control and
efforts are required to reduce disease incidence. CRS prevention measures;
Surveillance data are essential for: ‡ providing evidence of the impact of
‡ documenting disease burden and interventions.
describing the characteristics of measles
cases;
‡ identifying high-risk populations; 4. Establishing and
‡ understanding the reasons for the
occurrence of the disease and developing
strengthening an
appropriate control measures; integrated measles/
‡ predicting, detecting and investigating rubella/CRS surveillance
outbreaks to ensure proper case
management and to determine why system
outbreaks have occurred (e.g. failure In order to achieve regional measles elimination
to vaccinate, vaccine failure, or an goals, one of the important strategies is
accumulation of susceptible persons). establishing effective surveillance for measles,
Measles surveillance also helps to including laboratory confirmation of cases
determine when the next outbreak might and outbreaks and an opportunity to assess
occur due to the build-up of susceptible the population immunity profile through the
persons and accelerates prevention vaccination status of cases.
activities beforehand;
‡ providing evidence that, in countries
with low measles incidence, the absence 4.1 General principles
of reported cases is attributable to The three main components of a measles/
the absence of disease rather than to rubella and CRS surveillance system are:
inadequate detection and reporting;
‡ detecting any importation of virus into ‡ detection and notification of suspected
cases;
a community and determining whether
‡ investigation, including active case
transmission is sustained, following an
searches, timely collection of blood
importation, from the size, nature and
samples and laboratory workup and final
duration of clusters and the genotypic
classification;
diversity of circulating viral strains;
‡ using surveillance data for action.
‡ monitoring progress towards achieving
disease control and elimination goals.

13
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

Effective surveillance systems are necessary at Given the similarities in clinical presentation,
the district, provincial and national levels. Such epidemiologic investigation and laboratory
systems need to be country-wide, sensitive and workup, surveillance for measles/rubella
case-based. Legislative changes may be required should be fully integrated (11). Reporting and
in countries where mandatory reporting does investigation of suspected cases of measles or
not exist for measles, rubella and CRS, to rubella should thus follow the same channels
facilitate the operation of the surveillance and procedures. Except for outbreaks, all
system. Countries are encouraged to use serum specimens of suspected cases should be
the infrastructure and operating procedures tested for both measles- and rubella-specific
(zero reporting, active surveillance, etc.) IgM.
of the existing acute flaccid paralysis (AFP)
surveillance system to develop measles, rubella  &RUHVXUYHLOODQFHIXQFWLRQV
and CRS surveillance systems. Core surveillance functions are case
detection, reporting, investigation (including
Measles, rubella and CRS surveillance should
confirmation of diagnosis), data analysis,
be case-based. A case-based surveillance system
interpretation and control activities. The
collects a core data set at national level on each
national level should establish the following
case, including but not limited to, information
standards for surveillance to achieve maximum
on age, gender, vaccination status, date of last efficiency and ensure that data are comparable
vaccination received, place of residence, travel throughout the country.
history, date of rash onset, disease outcome,
etc. Case-based surveillance allows for analysis ‡ Case definitions and guidance on final
of measles epidemiology to guide control classification of cases
efforts. ‡ Identification and reporting of measles/
rubella and CRS cases
 ,QWHJUDWHGGLVHDVHVXUYHLOODQFH ‡ Type of surveillance to be conducted
Many countries have multiple reporting systems (zero reporting, active surveillance)
for measles, such as programmes managed by ‡ Data to be collected and forms/data
the communicable disease programme, EPI collection tools to be used
programme and school health programme. ‡ Laboratory diagnosis methods
Ideally, countries should integrate these efforts ‡ Minimum data analysis by level (district,
in a unified system. This might be done within provincial, national)
the frame of integrated disease surveillance ‡ Procedures and indicators for monitoring
that should carry out many functions using surveillance quality
similar structures, processes and personnel. ‡ Routine reports to be produced
The surveillance activities that are well ‡ Surveillance data dissemination and the
developed in one area may act as driving forces use of data in decision-making.
for strengthening other surveillance activities,
offering possible synergies and common  &DVHGHÀQLWLRQV
resources. The integrated disease surveillance
strategy aims to improve the availability and  0HDVOHVFDVHGHÀQLWLRQ
use of surveillance and laboratory data for Case definitions according to which a measles
control of priority infectious diseases that are case can be classified are presented below.
the leading cause of death, disability and illness There should be widespread dissemination
in a country. of the national case definition to all health

14
Establishing/strengthening surveillance systems

workers, together with encouragement to laboratory classification of measles/


report cases, as needed. WHO recommends rubella (Figure 1).
the following clinical and laboratory case – Clinically confirmed: a case that meets
definitions of measles (10). the clinical case definition and for
‡ The clinical case definition of measles is: which no adequate blood specimen
– any person in whom a health care was taken.
worker suspects measles infection, or – Laboratory confirmed: a case that
– any person with fever and maculo- meets the clinical case definition and is
papular rash (i.e. non-vesicular), laboratory confirmed by detection of
and one or more of the following: IgM antibody in serum.
cough or coryza (i.e. runny nose) or – Epidemiologically confirmed: a case
conjunctivitis (i.e. red eyes). that meets the clinical case definition
‡ Measles laboratory criteria for diagnosis: and that is linked epidemiologically
presence of measles-specific IgM to a laboratory-confirmed case.
antibodies. Epidemiological linkage is defined
– All suspected cases should be classified as direct contact with another
into one of the four following laboratory-confirmed measles case or
mutually exclusive categories, i.e. another epidemiologically-linked case
laboratory-confirmed cases, clinically- within the last 7 to 21 days before
confirmed cases, EPI-linked cases onset of illness.
or discarded cases, by using the

Measles IgM /DERUDWRU\FRQÀUPHGPHDVOHV


positive

Adequate
specimen
0–28 days
Laboratory-
Rubella
FRQÀUPHG
Measles IgM IgM positive
rubella
negative

Suspect Rubella IgM


measles case Discard
negative

EPI-linked (contact (SLGHPLRORJLFDOO\FRQÀUPHG


of a laboratory- measles
FRQÀUPHGFDVH

(SLGHPLRORJLFDOO\FRQÀUPHG
No specimen rubella

Not EPI-linked

&OLQLFDOO\FRQÀUPHGPHDVOHV

Source: Pan American Health Organization, Pan American Sanitary Bureau, Regional Office of the World Health Organization.
Measles and rubella surveillance integration in the Americas. EPI Newsletter, 2000, 22:45.

Figure 1. /DERUDWRU\FODVVLÀFDWLRQRIPHDVOHVUXEHOODVFKHPH

15
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

– Discarded: A suspected case that vaccines and who subsequently develop a rash,
has had an adequate investigation, would ideally be reported as a suspected case
including collection of a blood and usually have an IgM-positive result (11).
specimen during the appropriate time Second, the specificity of the kits for the
frame, but lacks serologic evidence of detection of measles- or rubella-specific IgM
a measles virus infection. (i.e. the ability to rule out a measles or rubella
Suspected cases that have no specimen or virus infection) is not 100%. Some patients
equivocal laboratory results but are also with eruptive (rash) illness, such as dengue
confirmed as another disease may be discarded. or erythema infectiosum, may test positive
Also, cases that are EPI-linked to confirmed for measles- or rubella-specific IgM. The Pan
cases of other communicable diseases should American Health Organization (PAHO) uses
also be discarded as non-measles (e.g. a the following five clinical and epidemiological
suspected case that is EPI-linked to a laboratory- criteria for the classification of measles case as
vaccine-related (11).
confirmed rubella case during a rubella
outbreak). Suspected measles cases should be ‡ The patient had a rash illness, with or
classified by qualified health workers (doctors, without fever, but did not have cough or
epidemiologists, laboratory personnel, etc.) at other respiratory symptoms related to the
the district or provincial level. rash.
‡ The rash began 7–14 days after
The case definition given above has a high
vaccination with a measles-containing
sensitivity for measles. However, countries
vaccine.
may elect to choose to use the case definition ‡ The blood specimen which was IgM-
“rash and fever” to make the surveillance positive was collected 8–56 days after
sensitive enough to detect all measles cases vaccination.
and meet the criteria for measles elimination. ‡ A thorough field investigation did not
However, suspected cases may not be “true identify an index case or any secondary
measles cases”, particularly in areas of low cases; and
measles prevalence. As the incidence of ‡ Field and laboratory investigation failed
measles decreases, individuals meeting the to identify other causes (including the
clinical case definition will increasingly inability to identify wild-type measles
have rash illnesses other than measles, such virus in culture).
as rubella, roseola infantum, scarlet fever,
etc. For these reasons, WHO recommends Based on the infection source, confirmed cases
enhanced measles surveillance based on the should further be classified into one of three
serological confirmation of all suspected cases mutually exclusive categories.
of measles, once the case load has been brought ‡ An imported measles case is a
down through the implementation of effective confirmed case which, as supported
measles control interventions (10). by epidemiological and/or virologic
evidence, was exposed outside of the
 9DFFLQHUHODWHGFDVHV country during the 7–21 days prior to
Two situations exist in which an IgM-positive rash onset. For rubella, the time frame is
result is not associated with a case having a 12–23 days.
wild-type measles virus. First, patients (up to ‡ An import-related case is a confirmed case
5% of those vaccinated) who were recently which, as supported by epidemiological
vaccinated with measles- or rubella-containing and/or virologic evidence, was exposed

16
Establishing/strengthening surveillance systems

locally as part of a transmission chain specific IgM. The blood specimen should
initiated with an imported case. be obtained within 28 days of rash onset.
‡ A case with unknown source of infection ‡ Epidemiologically-confirmed rubella
is a confirmed case for which the source of case: a patient with a rash illness that is
infection was not identified. linked epidemiologically to a laboratory-
Classification of confirmed cases by infection confirmed rubella case.
source is critical to evaluate whether
endemic circulation of measles virus has been  &56FDVHGHÀQLWLRQ
interrupted or, if interrupted, re-established The following case definitions are recommended
in a country. In particular, re-establishment of for the surveillance of CRS (12).
endemic transmission is defined as a situation ‡ Suspected CRS case: an infant less than
in which a chain of transmission continues one year of age in whom a health worker
uninterrupted for a period of more than 12 suspects CRS. A health worker should
months. Classification of measles cases should suspect CRS when an infant (0–11 months
be done through regular and frequent meetings of age) presents with heart disease or
of surveillance, laboratory and EPI staff. suspicion of deafness or one or more
For surveillance purposes, a measles death is of the following eye signs: cataract,
defined as any death from an illness that occurs diminished vision, nystagmus, squint,
in a confirmed case of measles within one microphthalmos or congenital glaucoma.
month of the onset of rash.3 The immediate A health worker should also suspect CRS
and delayed complications of measles, such as when an infant’s mother has a history of
pneumonia or persistent diarrhoea, which are suspected or confirmed rubella during
the complications most responsible for measles pregnancy, even when the infant shows no
deaths, may manifest and result in death much signs of CRS.
later than the disappearance of the rash. ‡ Clinically-confirmed CRS case: An infant
in whom a qualified physician detects two
 5XEHOODFDVHGHÀQLWLRQ of the complications listed in a) below or
The following case definitions are recommended one in a) and one in b).
for the surveillance of rubella (12). a) cataract, congenital glaucoma,
‡ Suspected rubella case: a patient of any congenital heart disease, loss of
age in whom a health worker suspects hearing, pigmentary retinopathy.
rubella. A health worker should suspect b) purpura, splenomegaly, microcephaly,
rubella when a patient presents with mental retardation, meningocephalitis,
fever, maculopapular rash and cervical, radiolucent bone disease, jaundice that
sub-occipital or post-auricular adenopathy begins within 24 hours after birth.
or arthralgia/arthritis. ‡ Laboratory-confirmed CRS case: An
‡ Clinical confirmation: rubella cannot infant with clinically-confirmed CRS
be confirmed clinically; laboratory who has a positive blood test for rubella-
confirmation is required. specific IgM (100% of such infants will
‡ Laboratory-confirmed rubella case: a be positive at age 0–5 months and 60%
laboratory-confirmed case is a suspected at age 6–11 months). Where special
case with a positive blood test for rubella- laboratory resources are available,
3
This definition should exclude deaths due to obvious non-
detection of rubella virus in specimens
measles causes (e.g. accidents, etc.). from the pharynx or urine of an infant

17
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

with suspected CRS provides laboratory of CRS is low in women infected after the
confirmation of CRS (60% of such infants first trimester);
shed rubella virus at age 1–4 months, 30% ‡ Maternity hospitals, paediatric hospitals
at 5–8 months, and 10% at 9–11 months). and neonatal intensive care units;
‡ Congenital rubella infection (CRI): When ‡ Reference facilities treating children with
a woman is diagnosed with suspected or cataract, deafness or congenital heart
confirmed rubella during pregnancy, her disease.
infant should have a rubella-specific IgM
blood test. An infant who does not have
clinical signs of CRS but has a positive 5. Surveillance
rubella-specific IgM test is classified as activities and procedures
having CRI.
for measles, rubella and
4.3 Reporting sites CRS
Each country may decide about the reporting
In establishing and conducting measles,
sites to include in the surveillance system
rubella and CRS surveillance activities, the
for measles, rubella, CRS or for vaccine-
roles and responsibilities of health workers
preventable diseases in integrated disease
surveillance. However, this decision and authorities at different levels of the health
needs to be made without compromising care system need to be defined and reporting
representativeness, accuracy and quality of procedures developed.
information and resources. The following are
suggested sites. 5.1 Health facilities
‡ Primary health care facilities: health
centres, health units and inpatient and  5HSRUWLQJDQGLQYHVWLJDWLQJ
outpatient clinics; measles and rubella cases
‡ Hospitals, both inpatient and outpatient ‡ Identify suspected measles/rubella cases.
units; Health care workers should use the case
‡ Private medical practitioners and private definitions described above to identify
hospitals; suspected measles/rubella cases. The
‡ Private and public laboratories: it definition of suspected cases is meant to
is important to establish routine be broad and sensitive.
communication with all local laboratories ‡ Notify all suspected measles/rubella cases.
that may receive serum specimens for Designate one individual and one or two
diagnosis of suspected measles/rubella alternates to be responsible for keeping
cases; track of suspected measles cases and to
‡ Community sources: pharmacists, village report immediately all new suspected
leaders, school personnel and anyone else measles cases. Health care workers should
likely to learn about or have contact with immediately notify all suspected cases
sick children. to district surveillance authorities. The
For CRS surveillance, reporting sites may channel of notification should be simple
include the following. and efficient, with a designated reporting
‡ Antenatal clinics visited by women during form used for notification. A sample form
the first 16 weeks of pregnancy (the risk that may be considered for notification

18
Surveillance activities and procedures

and investigation of suspected cases of to document their outcome. All suspected


measles and rubella is given in Annex 1. CRS cases in infants under one year of age
should be investigated and both clinical
Regional measles elimination goal: measles and analytical findings should be included.
suspected cases reported within 7 days of
UDVKRQVHW• ‡ Send the weekly surveillance report
summarizing the number of suspected
‡ Immediately collect specimens for cases seen in the previous week to the
laboratory testing. Blood and clinical district surveillance unit. This is usually
specimens for virus isolation should be done on a specific day each week.
collected in designated health facilities Maintain weekly reporting even if there
from all suspected cases. A copy of the are zero cases (often referred to as “zero
notification and investigation form should reporting”). The health facility should
be sent with the specimen. Preparation of use a standard form to report suspect
the specimen for shipment is discussed in measles/rubella cases, acute flaccid
detail in Section 8. paralysis and other vaccine-preventable
‡ Investigate all suspected measles cases. See diseases (for an example of a form see
Sections 6 and 7 for details. Annex 2).
‡ Conduct case-based measles/rubella
surveillance by collecting a minimum data  ,QIRUPDWLRQV\VWHPDQGGDWD
set on each case. A standard reporting analysis
form should be completed for each case of ‡ Record all suspected measles cases in
suspected measles/rubella. The following a registry with the age and vaccination
items of information are of major status for each case.
importance.4 ‡ If possible, data should be entered into
– date of birth or age a database at health facility level. Initial
– date of rash onset data can be analysed at the health facility
– date of blood specimen collection level and further case-based data can be
forwarded to the district.
– district of residence at time of rash
‡ Data from notifications, investigation
onset
forms and line-listings should be analysed
– history of immunization against to monitor reported suspected and
measles and rubella and date of last confirmed cases by age, sex, location
vaccination and vaccination status, and to determine
– manage measles cases appropriately whether standards for case reporting and
(see Sections 7 and 8 for details). investigation are being met.
‡ Identify clusters or outbreaks and ‡ Health facilities should promptly detect
immediately notify them to the district. all suspected outbreaks during analysis of
‡ Conduct an intense search for pregnant the data, through an investigation of the
women exposed and potentially infected distribution of cases by area and reporting
with rubella. Any pregnant women who unit.
have been infected need to be followed-up ‡ Case-based information collected through
4
case investigation forms and line-listings
Recommendations of the regional measles technical advisory
group. Report on the Intercountry meeting on measles and rubella (Annex 3) should be sent (on a specific
control and elimination and laboratory network, 27–30 November, day of the week) from the reporting site
Amman, Jordan. Cairo, WHO Regional Office for the Eastern
Mediterranean 2006 (WHO-EM/EPI/259/E). to the district surveillance unit, as a file

19
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

containing all individual case forms and a ‡ Investigate and document outbreaks of
line list. If a reporting site has the capacity measles (see Section 7 for details).
for data entry, then the case investigation ‡ Investigate all CRS cases and monitor
forms can be entered into a database or CRS rates (an example of a CRS case
spreadsheet, and soft versions can be sent investigation form is given in Annex 4).
on a memory device or through e-mail. The annual number of CRS cases should
be reported to the national level. To
5.2 Districts calculate the rates, it will be necessary
to define the catchment area for cases
 6XSSRUWLQJKHDOWKIDFLOLWLHV and the annual number of live births in
‡ Respond to the needs of the reporting that catchment area. CRS surveillance
units (health facilities), assist and supervise should be enhanced in the context of a
their work, and resolve any technical rubella outbreak, particularly during 6–12
problem as soon as possible. Surveillance months post-outbreak to identify births
staff should monitor surveillance quality to women who may have been infected
indicators through field visits, surveillance during the outbreak. Up to 50% of rubella
review meetings, and regularly-organized infections may be asymptomatic, which
training workshops. means that pregnant women may not have
‡ Conduct periodic active case searches been ill and may not have known that they
to ensure that all suspected cases are had rubella infection.
identified and notified. Active case-
finding is particularly important in areas  ,QIRUPDWLRQV\VWHPDQGGDWD
that do not notify cases, such as “silent” analysis
and high-risk areas. Case-finding is ‡ Generate a measles/rubella database. Data
primarily conducted in health facilities on all reported cases from all reporting
(clinics and hospitals) but can also be sites should be entered into database
performed in institutions, schools and within 3 days. A weekly report should be
in the community. In health facilities, sent to the provincial level.
registration records, discharge diagnoses ‡ Analyse measles/rubella/CRS data. The
and hospital charts are reviewed to district officials should analyse weekly
identify patients with fever and rash and should send a monthly report (in
illnesses, such as dengue and scarlet the first week of every month) to the
fever. In local laboratories, the logbook provincial surveillance unit. The data
should also be checked to ensure that entered should be transferred immediately
all suspected cases are being reported from the district database to the PSU data
promptly. If potential cases are spotted, provincial surveillance unit by uploading
medical records should be reviewed through the Internet or through a
carefully and the physician or nurse who computer storage device.
provided care to the individual should be ‡ Interpret surveillance data in conjunction
interviewed to determine whether the with routine immunization coverage data.
patient met the criteria of a suspected Analyses should be aimed at understanding
measles/rubella case. If so, it must then the reasons for the occurrence of measles,
be determined if the case was reported obtaining guidance for control strategies,
and adequately investigated. predicting potential outbreaks in order
to implement vaccination strategies for

20
Surveillance activities and procedures

the prevention of outbreaks and planning 5.3 Provinces


measles elimination strategies (13). A few
‡ Ensure adequate and proper supervision
simple graphs can provide the essential
and provide technical support to the
data (i.e. time, place and person).
districts.
– Number of cases by month of report
‡ Review and clean up data received
compared over several years.
from the district before merging and
– Number of cases reported by health transferring it to the national level. In case
facility (spot map). Cases should of delays in data transfer, provincial staff
be plotted on a map according to should contact district staff by phone to
their place of residence and the map urge them to send the data. Transfer of
compared with vaccination coverage data to the national level could be done
data and sites reporting in the through uploading or by sending a storage
surveillance system. These maps can device.
be useful for coordinating activities, ‡ Transmit reports received from the
such as setting up vaccination sites. districts to the national level on a weekly
– Number of cases by age group basis.
and vaccination status (cumulative ‡ Analyse disease patterns and trends,
for the year). Tabulating the age interpret surveillance data in conjunction
distribution of cases permits health with routine immunization coverage data,
authorities to detect any changes produce routine and activity reports and
in the epidemiology of the disease share results with district, provincial and
and to establish which age groups to national staff. The calculation of incidence
target for vaccination. Determining rates, e.g. the number of measles cases
the vaccination status of confirmed divided by the population at risk, is
cases is essential for evaluating vaccine especially useful at the provincial level
effectiveness and detecting potential for comparing the occurrence of disease
problems with the cold chain. at different places and times. In order to
calculate rates accurately, it is important
‡ Whenever information on vital status/
to obtain accurate population figures.
deaths is available, analyse the number Population data can be obtained from the
of measles-related deaths by age group census bureau or can be assessed by special
and vaccination status (cumulative for surveys performed by various institutions
the year). Such data are essential for or by health facilities.
measuring progress towards measles ‡ Monitor the surveillance performance
mortality reduction and for targeting using standard indicators and assess the
appropriate control measures. programme as a whole by implementing
‡ Review any areas that do not report an evaluation plan every six months (see
cases for extended periods. If such areas Section 9 for details).
exist, it is important to identify at least
one reporting site, e.g. a hospital or 5.4 National level
large clinic and include it in training
‡ Supervise and provide technical support,
programmes and prompt reporting
as well as training, guidelines and logistic
procedures.
support to all levels of the surveillance
programme, including assistance with

21
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

budgeting and finance and managerial ‡ Coordinate and integrate national


support. The national level should surveillance activities and provide
produce and distribute surveillance reliable surveillance data and reports to
guidelines, including case definitions, responsible public health officials.
reporting forms and case investigation ‡ Generate a monthly (or more frequently)
guidelines. report about the current situation of
‡ Develop and support data management vaccine-preventable diseases under
software to be used at the provincial and surveillance. Surveillance staff at national
district level, including data entry screens, level should conduct monthly surveillance
report generators and electronic reporting meetings, data analysis, the epidemiologic
procedures from provincial to national situation and progress in all provinces and
level. districts (such a meeting can be conducted
‡ Receive and merge data transferred from quarterly or twice a year with staff at each
all provinces on a weekly basis and ensure province and district).
consistency and validity of national data. ‡ Provide surveillance data and summaries
‡ Monitor the surveillance performance to relevant ministry of health disease
using standard indicators (Section 9). control programmes and officials and
In case of delays in data transfer from other stakeholders, i.e. EPI diseases,
any site, the coordinator should contact other communicable diseases, public
the province by phone and urge officials health laboratories, WHO Regional
to send data and solve any technical Office, national immunization technical
problems causing delay. advisory group (NITAG), and other
‡ Confirm cases and outbreaks using IgM relevant departments. Timely data should
serologic testing in a WHO proficient be provided to the Regional Office
national measles/rubella laboratory, and and other related programmes in the
organize a possible shipment of specimens country. Reporting to the Regional Office
for viral isolation and genotyping. involves monthly reporting of case counts
The national level needs to coordinate according to an agreed-upon standardized
epidemic preparedness at all levels and to format (Annex 5).
function as the central point for response
for reported or identified outbreaks or
rumoured outbreaks.
6. Investigating and
‡ Use measles surveillance data to evaluate managing measles,
national objectives and to direct the rubella and CRS cases
control programme. National officials
should analyse disease patterns and trends, Prompt recognition, reporting and
interpret surveillance data in conjunction investigation of measles/rubella cases are
with the routine immunization coverage important because the spread of the disease
data and produce routine reports. They can be limited with early case identification
should conduct in-depth epidemiological and vaccination of susceptible contacts. Once
analysis (disease trends, high-risk groups, endemic transmission has become rare or has
high-risk areas and progress towards been interrupted, the surveillance goal is to
elimination) from national surveillance detect and investigate all suspected measles
data. cases and outbreaks, including those imported,

22
Investigating and managing cases

and to implement activities that prevent or During the elimination phase, plans should be
limit secondary transmission. made to visit the home of the patient within
48 hours of notification. An investigation
includes, at a minimum, a home visit with
6.1 Measles case investigation
clinical and epidemiologic investigation of the
Investigation of measles/rubella suspected suspected case and contacts of the suspected
cases should be conducted within 48 hours case and completion of relevant data (district,
of notification. If the patient meets the case age, gender, date of onset, known vaccination
definition for measles, use the case investigation status, date of last measles/rubella vaccinations,
forms (Annex 1), submit them to district and/ date when specimen was collected, travel
or provincial surveillance coordinators, and history). The health facility then needs to
update the line list of suspected measles/rubella complete an individual case investigation form
cases (Annex 3). Health care workers should for each patient (Annex 1).
ask parents if they know anyone else in their
household or village/town that has a fever and Correct timing of specimen collection with
rash. It is important to ensure completeness of respect to onset of clinical signs is important
all data collected, such as date of notification for the interpretation of results and reaching
and date of investigation. an accurate conclusion. A serologic specimen
needs to be collected within the 28 days of
the onset of rash. Investigators should collect
Regional measles elimination goal: a specimen and arrange for its transportation
percentage of suspected measles cases to the national measles laboratory. The
LQYHVWLJDWHGZLWKLQKRXUVRIQRWLÀFDWLRQ
•
blood sample should be taken during the first
contact with the suspected patient as soon as
possible following rash onset, unless it can be
Suspected measles cases should receive a case arranged for the patient to provide a sample
identification number (case ID number) to aid on day 3 or 4 of the rash. The sample could be
in case tracking. This case number should begin collected either at the health facility or during
with one or more three-letter combinations a home visit, using a specimen collection kit
to designate the geographic location, and ensuring a well-executed reverse cold
followed by the year and the case number. chain when transporting the specimen to the
All communications and forms related to the health facility. Blood specimens must arrive
case should cite the identification number. For at the laboratory within 7 days of collection.
example, a unique EPID number in the case Laboratory request information should be
investigation form to each suspected case with included in the case investigation form. For
the following format. countries using a separate form for measles/
Country code/Province code/District ID/Year/ rubella laboratory testing, a template is
MSC/Case serial # # # #. Some countries add provided in Annex 6.
MSC: measles suspected case. The four digit
serial case # will be an incremental number
Regional measles elimination goal:
per year. percentage of cases with blood specimen
collected (exclude epidemiologically-linked
A suspected case of measles needs to FDVHVIURPGHQRPLQDWRU •
be investigated thoroughly. Clinicians,
epidemiologists and/or other specially trained
staff should be in charge of the investigation.

23
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

Active case-finding should be conducted even  &DVHPDQDJHPHQWRI


if there are more than 10 suspected cases XQFRPSOLFDWHGPHDVOHV 
and should be combined with AFP active Many children will experience uncomplicated
surveillance. However, this would depend measles and will require only supportive
on time and resources. Contact tracing may measures.
identify the source of infection and determine ‡ Give vitamin A if the child lives in an area
whether other areas have been exposed.5 of known deficiency or high measles case-
Surrounding areas should be visited to find fatality rates.
additional cases. Inquiries should be made ‡ Advise mothers to treat the child at home
to determine whether cases are occurring in as long as no complications develop.
places visited by the ‘case under investigation’ ‡ Provide nutritional support: continue
between 7 and 21 days prior to the onset of breastfeeding or give weaning foods
the rash, such as a preschool centre, school and fluids at frequent intervals and treat
or another town or village. Surveillance sites mouth ulcers.
and surveillance coordinators in nearby areas ‡ Control fever by keeping the child cool.
should be informed that a suspected case has ‡ Instruct the caregiver to return for further
been identified and the public should be kept treatment if the child’s general condition
well informed. Community leaders should also worsens or if any of the danger signs
be asked to assist in case-finding. Investigators develop.
should call local private medical doctors and ‡ Explain to mothers that there is an
inform them about the suspected measles/ increased risk in the weeks following
rubella outbreak, as well as the mandatory a measles infection of diarrhoea, acute
notification of any suspected patient, and ask respiratory infections and other infections,
and encourage them to seek medical
if they have seen any cases of fever and rash
advice promptly if these complications
illness.
develop.
Evaluation of vaccination coverage levels is ‡ Immunize direct contacts if they are
important to provide measles vaccination to identified within 72 hours of exposure.
unvaccinated persons. Prophylactic use of antibiotics is not
recommended for uncomplicated
Regional measles elimination goal:
cases. However, a Cochrane Review
SHUFHQWDJH RI LGHQWLÀFDWLRQ RI VRXUFH RI suggested a beneficial effect of antibiotics
LQIHFWLRQ• in preventing complications such as
pneumonia, purulent otitis media and
tonsillitis in children with measles (15).
6.2 Measles case
management  &DVHPDQDJHPHQWRI
complicated measles
Measles case management should be conducted Even in industrialized countries, about 10% of
through the IMCI approach, with the cases can be expected to develop complications
supplementation of vitamin A. of measles. In severe outbreaks in developed
5
In elimination settings, contact tracing and, if necessary, countries, this proportion will be higher and
active case search should be a routine practice. However, this some children may have several complications.
would not be feasible in countries where measles remains
highly endemic In developing countries, at least three-quarters

24
Outbreak investgations and control

of all cases can be expected to have at least one


complication and some may have multiple
7. Outbreak
systems involvement. The following actions investigations and control
should be taken when complications occur. for measles and rubella
‡ Refer to health facility for further
management. 7.1 Measles outbreak
‡ Follow the above recommendations
for case management of uncomplicated
investigation
measles. Health facilities and district staff will be
and responsible for investigating clusters of measles
‡ Ensure that two age-appropriate doses of cases and conducting good quality outbreak
vitamin A are given. investigations, including active case-finding in
‡ Clean eye lesions and treat with 1% the community, maintaining a line-list of cases
tetracycline eye ointment three times and implementing public health measures.
a day for 7 days (for corneal lesions,
cover the eye with a patch). Vitamin A  'HÀQLWLRQRIDPHDVOHVRXWEUHDN
administration is particularly important to All countries in the Region have conducted a
minimize the risk of potentially blinding one-time measles catch-up campaign. Hence,
eye lesions. In this situation, use a third using the WHO guidelines, a suspected outbreak
dose of vitamin A four weeks later using of measles is defined as the occurrence of five
the same dosage and age as in Table 1 or more reported suspected cases of measles in
(16). one month per 100 000 population living in a
‡ Clean ear discharge and treat with geographical area (e.g. district/health facility).
antibiotics. Antibiotics should be used for (14) A confirmed measles outbreak is defined
cases complicated by otitis media. as the occurrence of three or more confirmed
‡ Refer suspected cases of encephalitis to a measles cases (at least two of which should
hospital. be laboratory confirmed; IgM positive) in a
‡ Treat malnutrition and diarrhoea with district/health facility (approximate catchment
sufficient fluids and a high-quality diet. population of 100 000) in a month.
‡ Treat pneumonia with antibiotics.
 5HSRUWLQJPHDVOHVRXWEUHDNV
The health facility surveillance focal person
Table 1. Recommended vitamin A schedule should notify the district team about the
for measles treatment occurrence of clusters of cases using the
Age group Immediately on Next day
quickest available means of communication
diagnosis (phone, fax, e-mail, etc).
,QIDQWV ,8 ,8
months All outbreaks should be reported to WHO
,QIDQWV² ,8 ,8
Regional Office using a specific form (Annex
months 7) and thoroughly investigated using WHO
&KLOGUHQ ,8 ,8 guidelines for outbreak investigations (14).
months and
above
Regional measles elimination goal:
percentage of suspected measles outbreaks
LQYHVWLJDWHG•

25
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

 0HDVOHVRXWEUHDNLQYHVWLJDWLRQ confirmation is not possible, an outbreak


The district team should conduct the outbreak may be documented through a sustained and
investigation. All cases need to be investigated progressive rise in clinically-confirmed cases
to confirm that they meet the clinical case over a 3-week period (14).
definition, to assess the extent of the suspected The district team needs to create a line-listing
outbreak and to determine the population of all subsequent cases to include the age,
at risk. The investigation is best performed vaccination status, address, date of rash onset,
by health workers trained to identify clinical outcome and case ID number (Annex 2)
measles cases, using a standard form to obtain Provincial staff should inform national
details on cases and contacts (Annex 1). If authorities and the community through
there are >10 suspected cases in each single the effective use of public health messages
area, the household visits may be reduced or regarding appropriate treatment of cases,
eliminated, depending upon the availability immunizations to be given, and other control
of investigators. However, the suspected measures. Figure 2 illustrates the importance
case line-listings should be filled out for each of conducting an active search of cases during a
suspected case and particular attention should measles outbreak.
be given to obtaining basic demographic data,
including the age and vaccine history of the The data collected should be analysed rapidly
patient. at the local level to determine the extent of the
outbreak and the population at risk. This can
All suspected measles outbreaks should be be done by analysing a line-listing of cases with
confirmed as having resulted from measles key variables (Annex 3) or, more efficiently,
virus infection. Blood samples, as well as by entering the data into a computer program
other clinical specimens for viral isolation and such as Epi-InfoTM, Access or SPSS. Figure 3
genotyping, should be taken from the first 5–10 shows the distribution of suspected measles
suspected cases within an affected geographical cases by age group reported in a province in
area for laboratory confirmation (the presence Iraq in 2008. It shows that 58% of total cases
of measles-specific IgM antibodies) of the were under-5 years of age and 17% of cases
outbreak in that area. If there is any suspicion were above 15 years of age, which reflects
that the outbreak has spread to an adjacent area, weaning of immunity at the older age group.
5–10 blood specimens should also be collected
from suspected cases in that area, unless there  0HDVOHVRXWEUHDNUHVSRQVH
is clear epidemiologic linkage between the
two areas/districts. Once a measles outbreak Types of outbreak response
is laboratory confirmed, it is unnecessary The response to the outbreak needs to be
to collect specimens from every suspected developed fast and aggressively (14). The
case. Additional cases can be confirmed if type of outbreak response varies, depending
they meet the clinical case definition and are on a number of factors, including the level of
epidemiologically linked to a laboratory- susceptibility in the population, risk for spread
confirmed case or to another EPI-linked case. and complication and the existing health service
infrastructure.
Laboratories are recommended to report
laboratory results within 7 days of receipt; In order to enhance the capacity to respond
however, during outbreaks, laboratories to measles outbreaks, a district level outbreak
should provide the IgM results within 24 hours coordination committee or any equivalent
after the receipt of specimen. If laboratory subnational level multidisciplinary group

26
Outbreak investgations and control

EPI data Active surveillance data


1800
1600
1400
Number of cases

1200
1000
800
600
400
200

0
ry

ary

rch

ril

st

er
Ma

be

be

be
Jul
Jun

gu
Ap
ua

mb
bru

Ma

to

vem
Au
Jan

pte

ce
Oc
Fe

No

De
Se
Month
Source: Technical report from the Expanded Programme on Immunization, Ministry of Health, Pakistan, 2005 (unpublished data).

Figure 2. &RPSDULVRQRIPHDVOHVFDVHVE\(3,GDWDDQGDFWLYHVHDUFKGDWD3DNLVWDQ

7
6
5
4
3
2
1
0
<1 Year 1–2 Years 2–3 Years 3–5 Years 5–15 Years >15 Years
Age 4 group

Source: Technical report from the Expanded Programme on Immunization, Ministry of Health, Iraq, 2008 (unpublished data).

Figure 3. 6XVSHFWHGFDVHVRIPHDVOHVE\DJHJURXS1LQDZD,UDT

should be created prior to the occurrence (such as oral rehydration solution) and
of outbreaks. The outbreak coordinating antipyretics.
committee should ensure that the following ‡ antibiotics should be used for cases
actions are carried out. complicated by otitis media or
‡ laboratory confirmation of the outbreak pneumonia, and nutritional therapy is
‡ ensuring adequate clinical management of indicated for children with malnutrition.
cases ‡ Intensifying surveillance and notification
‡ administration of vitamin A of suspected cases.
‡ supportive treatment should be provided Once an outbreak is confirmed (or before,
for all cases, including additional fluids if circumstances indicate), surveillance

27
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

staff should immediately notify other events that will result in increased
health facilities, clinicians, and surveillance opportunities for spread
coordinators in surrounding areas and the – number of cases reported and
appropriate surveillance staff at the district and comparison with data from previous
provincial levels. Active surveillance and case- years
finding need to be intensified in the outbreak
– access to health services.
area and surrounding areas.
Health staff at the health facility or district level Implementing control and preventive measures
should be vigilant and investigate any reports (including vaccination activities)
or rumours of measles cases occurring in the ‡ Managing cases and contacts to limit
community, or when there is an epidemic spread. It is important to ensure adequate
occurring in a neighbouring area. Such clinical management of measles cases in
investigations should either confirm (or reject) order to reduce measles mortality. In
the existence of measles virus circulation. addition, if time and resources permit,
the following measures should be
Assessing the risk of a large outbreak with high implemented, as follow-up of all cases
morbidity and mortality and contacts may not be possible if the
As soon as the outbreak is suspected the risk epidemic is large and if resources are
of a large outbreak with high morbidity and limited.
mortality must be assessed. This assessment is As soon as the outbreak is confirmed, the
needed to determine what type of vaccination district outbreak coordination committee
response is most appropriate to control the should review risk-assessment results and
outbreak. For this, the following evaluations decide accordingly whether to continue with
should be carried out. the selective vaccination activities or to carry
‡ Evaluate the susceptibility of the out a nonselective vaccination campaign.
population and potential for spread both
in the affected and neighbouring areas. Selective vaccination activities
‡ Evaluate the risk of further transmission, The following selective vaccination activities
morbidity and mortality. For this, the should be undertaken.
following factors should be taken into
‡ Enhance social mobilization activities
account.
to inform affected communities about
– population characteristics, such as
the suspected outbreak, which specific
size, density, movement and setting
age groups of previously unvaccinated
(e.g. community spread throughout
children is targeted for measles
a district, or limited spread within
a subpopulation; resource-poor vaccination, and where parents should
settings). bring their at-risk children for vaccination.
‡ Vaccinate all children (6 to 59 months
– under-5 mortality rates
of age or determine the target age
– nutritional, including vitamin A, status group according to the local disease
– HIV prevalence in the population epidemiology) presenting to a health
– period of the year (considering facility or an outreach vaccination site
potential for seasonal outbreak) and without a history of measles vaccination
plans for any festivals or other social (either written or verbal).

28
Outbreak investgations and control

‡ Vaccinate hospital staff at risk of exposure, – information on locations and opening


and who have not been vaccinated. hours of health facility/vaccine posts.
‡ Reinforce routine vaccination. The district team should also complete and
Non-selective vaccination activity send the analysis of the outbreak by person
As soon as the outbreak is confirmed, and if (age distribution, vaccination status, etc. of
the risk-assessment results indicate that there cases), place (spot map), and time (“epidemic
is a high risk of a large measles outbreak, then curve”) to the provincial level within 2 weeks.
More comprehensive documentation needs to
the capacity to carry out a high-quality large-
be performed at the close of the outbreak.
scale immunization campaign should be rapidly
evaluated. Once the decision to intervene An outbreak of measles in a district is said to
has been made, it is critical to act as quickly have ended when no new suspected case of
as possible to minimize the number of severe measles is identified for more than 3 weeks, and
measles cases and deaths. when all neighbouring districts have also not
reported any cases for a similar period of time.
‡ Target population: choosing the
Step-by-step guidelines for measles outbreak
target population depends upon the
investigations are presented below. It should
susceptibility profile of the population.
be noted that the placement of these actions is
Key elements to consider are: 1) routine
not intended to indicate a chronological order
vaccination coverage and coverage during
for implementation. Many of these actions
supplementary immunization activities
should be taken simultaneously whenever the
(SIAs) in each birth cohort; 2) age-specific
outbreak is suspected or confirmed.
attack rates; 3) absolute number of cases.
‡ Ensuring effective community
 6WHSE\VWHSJXLGHOLQHVIRU
involvement and public awareness: when
measles outbreak investigation
an outbreak is confirmed, there is likely
It should be noted that the order of these actions
to be widespread public concern and
is not intended to indicate a chronological order
media attention. It is important to keep
for their implementation. Many of these actions
the public informed, to calm fear and
should be undertaken concurrently as soon as
encourage cooperation. Messages to the
the outbreak is suspected or confirmed.
community should be clear and concise,
using local terminology, and should &RQÀUPWKHGLDJQRVLV
convey the following.
‡ Serological testing for suspected measles
– existence of an outbreak and the
cases
benefits of measles vaccination;
– Collect one blood specimen at first
– signs and symptoms of the disease; contact from 5–10 suspected measles
– encouragement to parents whose cases.
children have had a recent rash and – Take the opportunity simultaneously
fever illness; to collect appropriate throat swab/
– the need to consult a health care nasopharyngeal swab or urine for viral
facility early after symptom onset; isolation from cases presented within 5
– instruction to parents to bring their days of rash of onset.
children to a health facility/vaccine – Establish virological link to a
post for vaccination; laboratory-confirmed case.

29
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

– Virus identification of the strain ‡ In each affected household, what was the
genotype. age and vaccination status of the first case?
‡ How long did the epidemic last? (EPI-
Identify and investigate suspected measles cases curve)
‡ Basic surveillance variables
– age, sex, residence Determine the source of outbreak
– date of rash of onset ‡ Classical epidemiology (Who acquired the
infection from whom?).
– date of last measles vaccination and ‡ Molecular epidemiology via genotyping
number of doses received analysis of measles virus isolates.
– date of collection of blood specimen
Determine risk factors for measles infection
– possible source of exposure 7–21 days
(analytical epidemiology)
prior to rash of onset
‡ Age and vaccination status of cases
– exposure to another laboratory- ‡ Place of exposure (school, office, etc.)
confirmed measles case ‡ Attack rates
– travel to foreign country with known ‡ Possible risk factors:
measles virus circulation – age group and vaccination status
– possible transmission to others 3 days – travel to areas where measles is
prior to onset of rash to 4 days after endemic
rash of onset. – occupation (e.g. health care, tourism
‡ Questions to be asked industry)
– Where was the patient born? – school/day care attendance
– When did patient move to current – visit to health facility
residence?
The national level, in collaboration with the
– Have there been other cases within the provincial and district levels, should document
household? the outbreak. Careful investigation of measles
– Where does the patient work/study? outbreaks can provide useful information
– How does the patient travel to work/ regarding factors that may have facilitated
school? measles virus circulation. The investigation
– Are there other cases in the may help to identify risk factors for measles
workplace/school? infection and provide information that can
be used to refine and improve the measles
– Where does the patient socialize (e.g.
elimination. To benefit from the investigation
market, club, school)?
and outbreak control activities, data and
– Are there other cases in these social conclusions from the outbreak need to be
groups, mosques, places of worship? published. The report should include the
Describe the outbreak following sections: introduction; surveillance
‡ What was the total number of confirmed methods; description of the outbreak; analysis
cases? of the outbreak; control measures; problems;
‡ What were the age distribution and conclusions and recommendations.
vaccination status of confirmed measles
cases?
‡ Which municipalities have measles
circulation occurring? (map)

30
Outbreak investgations and control

7.2 Rubella/CRS outbreak evaluation, laboratory testing and infection


investigation control guidelines for these infants.

There should be a special emphasis placed on Virus detectable in nasopharynx


the investigation of rubella outbreaks as such Virus detectable in blood
outbreaks may provide an opportunity to Rash

obtain information on the CRS disease burden.


CRS cases are likely to be under-reported CD8
IgG

Relative levels
in areas and among populations where a T cells

high proportion of births occur at home and


where neonatal and childhood deaths are
CD4 IgM
often unreported. In such settings, outbreak T cells
investigations can help to identify CRS cases. Immune Suppression
Because rubella outbreaks tend to persist for -14 -7 0 7 14 21 28 35
several months or more and because CRS is a I f R h
Days after onset of rash

late outcome of these outbreaks, there is time


Source: (17)
to conduct active surveillance for CRS.
When a rubella outbreak is detected, Figure 4. Immunity responses of an acute measles
investigations need to be conducted, including infection
laboratory tests of a small number of suspected
rubella cases per month (5 to 10 investigations
Virus detectable in nasopharynx
per month, except in the accelerated or Virus detectable in blood
elimination control phase when all cases need Rash
to be investigated). All febrile rash illnesses IgG
during pregnancy should be identified,
Relative levels

investigated and followed. If rubella cases


are reported in individuals >15 years of age,
active surveillance should be conducted until IgM
9 months after the end of the outbreak, to
identify suspected CRS cases in infants 0–11
-2 -1 0 1 2 3 4 5 6 7 8 9 10 11
months of age. Weeks after onset of rash
Infection Rash
onset
All pregnant women infected with rubella
should have their pregnancy monitored Source: (17)
to document the outcome. Follow-up of
pregnant women should be an integral part of Figure 5. Immunity response in typical rubella
CRS surveillance. A pregnancy registry should LQIHFWLRQ 15
be created to assist districts in the follow-up
of these women. CRS surveillance should be
established in hospitals where these women
will be delivering and at specialty hospitals and
clinics or specialists where these infants will be
diagnosed or treated. All CRS cases should be
investigated using the form in Annex 4. There
should be a protocol in place for the clinical

31
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

collection. If specimens for viral isolation are


8. Laboratory support collected but not shipped along with the blood
in measles and rubella specimen, they should be kept in an adequate
surveillance storage. Procedures for the collection, handling
and shipment of specimens for measles/rubella
Laboratory testing to confirm a clinical testing are presented in Annex 8.
diagnosis of measles/rubella is an essential
part of the surveillance system. Each country It is critical for the laboratory to receive
needs to establish a system and procedures for case information with specimens. Blood
collecting and testing blood samples from cases specimens must be sent with a completed
of suspected measles and rubella following the copy of the case investigation form, including
Regional Office guidelines. Laboratory testing the following information: case identification
should be done in a WHO proficient national number, patient’s name, age, county/
measles/rubella laboratory. To be discarded, municipality, travel history, number of
a suspected measles case must undergo an vaccine doses received, date of last measles/
adequate epidemiological investigation and rubella vaccination, date of rash onset, date
have a negative laboratory result for measles- of notification, date of investigation, date of
specific IgM in a blood sample collected within blood specimen collection, date specimen was
an appropriate time period (28 days from rash sent to the laboratory and case classification.
onset).
Laboratories should conduct ELISA testing to
detect specific IgM class antibodies to measles.
8.1 Measles/rubella serology WHO recommends using commercially
Any suspected measles case should have available ELISA assays that are independently
a laboratory test undertaken. Accurate validated, have high sensitivity and specificity,
laboratory confirmation depends on the proper and are unaffected by haemolytic, lipaemic and
and timely collection, processing, shipment icteric sera (17).
and storage of specimens, as well as accurate Measles-specific IgM antibodies appear first
testing by a proficient laboratory. and can be detected shortly after rash onset.
They attain peak levels approximately one
Regional measles elimination goal: week later, then gradually decline and are
percentage of cases with blood specimen
collected (exclude epidemiologically-linked
rarely detectable at 6 weeks after rash onset
FDVHVIURPGHQRPLQDWRU • (Figure 4) (17). Ig G antibodies peak about 2
weeks following rash onset and are detectable
For measles surveillance, a single blood for years after infection.
specimen obtained shortly after rash onset may
be sufficient to confirm or discard suspected Regional measles elimination goal:
percentage of laboratory results available
measles cases. Specimens taken on day of rash
ZLWKLQGD\V•
may be IgM negative and a repeat serum may
be needed. Serum samples that are negative for measles
Once specimens are collected, they must be IgM should be tested for rubella IgM. Rubella
shipped to an official laboratory as soon as can be confirmed only by laboratory testing.
possible. Blood specimens must arrive at the Laboratory confirmation of rubella is made by
laboratory within 3 (maximum 7) days of detection of rubella-specific IgM in a blood

32
Laboratory support

specimen, which should be obtained within 28 that is not viewed as typical for measles/
days of rash onset (Figure 5). rubella (9).
If measles or rubella is suspected and a serum Serology cannot be used to rule out measles. A
sample obtained within the first 2 to 3 days after diagnosis should be considered confirmed in the
rash onset is negative for measles and rubella presence of good clinical and/or epidemiologic
IgM, it is recommended to obtain a second evidence, even in the absence of confirmatory
serum specimen within 10 to 20 days of onset serology. However, all suspected cases with
(13). This is especially true for rubella-infected an IgM-positive result should be considered
pregnant women. When serum samples are laboratory-confirmed and control measures
taken within 2 to 3 days after the rash onset, need to be initiated immediately.
up to 30% of ELISA tests for measles-specific
IgM may give false negative results and up to 8.2 Viral detection/isolation/
50% of rubella-specific IgM tests may give false
genotyping
negative results.
Efforts should be made to collect specimens
False-positive results of IgM tests can also occur; for virus isolation simultaneously with the
for example, exanthemata (rash illnesses) blood samples for serological confirmation
caused by Parvovirus B19, rubella and Human of measles and rubella as the cause of the
herpesvirus 6, among others, can be misdiagnosed outbreak. Collection of specimens for virus
as suspected measles cases. Each IgM positive isolation should not be delayed until laboratory
test that is thought to be false–positive needs confirmation of a suspected case of measles
to be considered on a case-by-case basis, taking is obtained. Throat swabs, nasopharyngeal
into account clinical presentation, vaccination specimens, or 10–50 ml of urine for virus
history, epidemiological data and laboratory isolation must be collected within 3–5 days
results. of rash onset when the virus is present in high
If IgM results are thought to be false-positive, concentration.
the IgM test should be repeated with the same Viruses are sensitive to heat and their infectivity
enzyme immunoassay (EIA) to measure IgG decreases when samples are not kept cooled.
titer levels in paired sera (first sample collected It is important to transport samples to the
within 7 days of rash onset, second sample 2 laboratory under cold chain conditions within
to 3 weeks thereafter). When possible, viral 48 hours of specimen collection.
detection/isolation and avidity assays (rubella
only) should be done. Genomic sequencing of wild-type measles
virus isolates from laboratory-confirmed
To discard a suspected case with an IgM- cases will distinguish the origin of measles
positive result that is not related to a recent viruses as indigenous or imported, and thus
vaccination, laboratory results must confirm will corroborate whether the transmission
a diagnosis other than measles/rubella that is of indigenous measles strains has been fully
compatible with the clinical presentation of eliminated. Genotyping can also identify
the suspected patient. In addition, a thorough vaccine-related suspected cases. If the person
field investigation must have been conducted has been vaccinated within 6 weeks prior
and failed to identify any measles/rubella to serum collection, refer to Manual for the
cases (whether an index or secondary case). laboratory diagnosis of measles and rubella infection.
A suspected case should never be discarded Geneva, (17).
merely on the basis of a clinical presentation

33
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

8.3 Measles/rubella measles have access to laboratory testing with


laboratory network full integration of laboratory and surveillance
data. Every effort must be made to ensure
The WHO Regional Office for the Eastern that laboratory, epidemiologic and operational
Mediterranean has organized a network of personnel work closely together and possess:
national measles laboratories in all countries accredited capability to perform testing, in
of the Region. The network’s structure and addition to the need for well-trained scientists
functions at each level are described below. and technicians, adequate laboratory facilities
and resources to cover operating costs.
 5HJLRQDOUHIHUHQFHODERUDWRULHV
There are two regional reference laboratories, The duties of the national laboratory include:
one in Oman and one in Tunisia, which serve ‡ confirmation of the diagnosis of clinically-
as centres of excellence for the Region. The suspected measles using validated
functions of the regional reference laboratories commercial IgM ELISA kits;
include: ‡ collection and dispatch of samples for
‡ collaboration and evaluation of new virus isolation to the regional reference
diagnostic assays laboratory in Oman or Tunisia. For
‡ diagnosis of clinically-suspected measles viral isolation and genotyping, shipment
and rubella cases by serologic testing, to a regional reference laboratory can
virus isolation, and characterization be delayed until serological results are
of viruses, from samples collected by known;
national and subnational laboratories ‡ quality assurance which includes
‡ training and advising national laboratory performing annual proficiency testing,
staff referral of selected specimens to a
‡ quality control (validation of their own reference laboratory for validation, and
and national laboratory results using a performance of epidemiologically essential
gold standard) serological surveys;
‡ internal quality assurance through ‡ training activities.
assessing the sensitivity and specificity of Some countries experiencing logistical
their work through proficiency testing. difficulties in shipping samples to the central
The Oman and Tunisia regional reference laboratory are encouraged to maintain
laboratories have been identified as the measles subnational laboratories to facilitate the
sequencing reference laboratories for the shipment of samples for retesting and
Region, though several national laboratories strengthening virus detection capabilities and
within the Region also have the capacity to genotyping in the Region. Before establishing
sequence viruses. subnational laboratory networks, however, use
of alternative sampling techniques should be
 1DWLRQDOODERUDWRULHV considered as a means of overcoming logistical
All countries should have an accredited national and economic challenges.
laboratory for measles and rubella testing.
National laboratories should have strong links to 8.4 Alternative sampling
the immunization and surveillance units at the
ministry of health. National laboratories should techniques
be closely linked with the national programme The collection of blood specimens from infants
managers to ensure that patients with suspected and young children is always a challenge, and

34
Surveillance monitoring and feedback

maintaining the cold chain during transportation specific to measles and rubella viruses, oral
of specimens to the laboratory is not always fluid can also be used for viral genome detection
possible. Recently, two approaches have been using reverse transcriptase-polymerase chain
validated for use in the WHO measles and reaction (RT-PCR). Oral fluid testing provides
rubella laboratory network which have the almost equivalent sensitivity and specificity
potential to be useful tools for measles/rubella for measles-specific IgM detection, though it
surveillance, namely, the use of dried blood shows moderately lower sensitivity for rubella
spots and oral fluid samples (17,18). Therefore, IgM (22). In addition, oral fluid samples have
countries are encouraged to utilize alternative a higher sensitivity for nucleic acid detection
sampling and transportation techniques, where than dried blood samples. Use of oral fluid
appropriate, for their measles and rubella samples creates an additional opportunity to
control programmes. Dried blood filter paper test for both antibody response (IgM) and the
and oral fluid can be used for case confirmation presence of virus in the same sample.
in areas where a reverse cold-chain is not
feasible logistically. Antibody and viral RNA 9. Surveillance
(ribonucleic acid) are sufficiently stable at
up to 37 °C for a week when such collection monitoring and feedback
methods are used. The standard protocols A high-quality surveillance system is essential
recommended by the measles and rubella to monitor progress toward and success in
LabNet are outlined in Manual for the laboratory sustaining measles elimination and rubella/CRS
diagnosis of measles and rubella infection (17). control. A quality surveillance system must be
maintained even after endemic measles virus
 'ULHGEORRGVDPSOHV transmission has been interrupted. All Member
Dried blood spots have been used for a number States should regularly and systematically assess
of epidemiological studies as an alternative the capacity of their surveillance systems to
specimen to serum for the detection of virus- ensure sufficient quality to monitor, measure
specific immunoglobulin G (IgG) and IgM. and report on measles, rubella and CRS,
Studies have shown that antibodies present in according to their elimination, control and
dried blood spots collected on filter papers are prevention goals. A set of standard indicators
stable for at least a month in the absence of a should be used to monitor the quality of a
cold chain, and can be detected for both measles measles/rubella surveillance system, and
and rubella viruses (19,20,21). See Annex 8 feedback should be provided to other levels
for specimen collection and transportation. and local staff.
 2UDOÁXLGVDPSOLQJ
Since the early 1990s, the United Kingdom 9.1 Surveillance performance
has successfully used oral fluid sampling indicators for countries with
for almost all measles, rubella and mumps elimination goal
laboratory-based surveillance. Use of oral
fluid samples enables field workers to obtain  5HSRUWLQJUDWH
a more complete sampling of suspected cases At national level, a rate of two non-measles
(21,22). Oral fluid samples are easy to collect suspected measles cases per 100 000 population
and, because the procedure is less invasive should be considered a minimum. These cases
than drawing blood, they are more accepted must have been investigated and discarded as
by the population. Beside the detection of IgM non-measles cases using laboratory testing in a

35
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

proficient laboratory6 and/or epidemiological LQLWLDWHGZLWKLQ”KRXUVRIQRWLILFDWLRQ7KH


linkage to another confirmed disease and /or numerator is the number of suspected measles
epidemiological linkage to an IgM negative cases for which an adequate9 investigation was
case. initiated within 48 hours of notification and the
denominator is the total number of suspected
In addition, at least one non-measles suspected
measles cases.
measles case should be reported annually
per 100 000 population in at least 80% of
the administrative units at the provincial 9.2 Measures of progress
level or its administrative equivalent or at an towards measles elimination
administrative level that has a population of at
To monitor progress towards elimination,
least 100 000.
there is a need to monitor population immunity
and measles incidence. One suggested indirect
 /DERUDWRU\FRQÀUPDWLRQ
measure of population immunity is vaccination
Specimens adequate7 for detecting measles
coverage. The incidence of measles cases per
IgM should be collected from at least 80% of
million population should be monitored to
suspected measles cases and tested in a proficient
assess progress towards reaching elimination,
laboratory. Any cases that are epidemiologically
and is another indirect measure of population
linked to a laboratory-confirmed case of
immunity. Incidence monitoring is reliable only
measles or other communicable disease should
when surveillance is of high quality (as indicated
be excluded from the denominator.
by meeting the surveillance performance
indicators above) and when thorough outbreak
 9LUDOGHWHFWLRQ investigation is carried out.
Samples8 should be collected for virus detection
from at least 80% of identified outbreaks Countries should conduct thorough outbreak
and tested in an accredited laboratory. The investigations of all outbreaks that include
numerator is the number of outbreaks with contact tracing and active case-finding, and
sufficient samples for viral detection and should determine the size, duration and
the denominator is the number of outbreaks origin of all outbreaks. As countries approach
identified. elimination, the size and duration of the
outbreaks will diminish and the majority of
 $GHTXDF\RILQYHVWLJDWLRQ outbreaks should be import-related in origin.
At least 80% of all reported suspected measles These measures are useful for providing
cases should have had an adequate investigation general guidance and may not apply to small
populations (particularly isolated small
6
A proficient laboratory is a WHO network laboratory
populations, e.g. small islands).
that uses a validated assay and has passed the annual WHO
proficiency test.
7
Adequate specimens are: serum; minimum of 0.5 ml, dried
blood sample; at least three fully filled circles on filter paper
collection device, oral fluid; sponge collection device should be 9
An adequate investigation includes at a minimum collection
rubbed along the gum until the device is thoroughly wet. This of all of the following data elements from each suspected
usually takes one minute. Samples should be collected within measles case: name or identifiers, age (or date of birth), sex,
0–28 days post onset. date of rash onset, date of specimen collection, vaccination
8
Where possible, samples should be collected from 5–10 status, date of last vaccination, date of notification and date
cases early in the outbreak and every 2–3 months thereafter of investigation, travel history, and district. In addition, the
if transmission continues. For virus isolation, throat or urine investigation should include contact tracing and additional case-
samples should be collected within 5 days after rash onset. For finding. Cases that do not require specimen collection (e.g.
virus detection using molecular techniques, throat samples can have been epidemiologically linked to a laboratory-confirmed
be collected up to 14 days and for oral fluid samples up to 21 case) are considered as adequately investigated if they have all
days after rash onset. the above information except the date of specimen collection.

36
Surveillance monitoring and feedback

The two measures below will be monitored at ‡ Proportion of reporting sites that report
the global level and are accompanied by markers ZHHNO\•
that suggest elimination has been achieved. ‡ Percentage of suspected cases with a blood
Regions and countries may add additional specimen received at the laboratory within
measures and markers as is appropriate for 3 (maximum 7) days of being taken:
the Region. Certification of elimination will > 80%
entail further analysis of the measures below ‡ Percentage of suspected cases with blood
(for example, an assessment of the reliability specimen processed within 7 days of
of coverage data in each country) and the use ODERUDWRU\UHFHLSW•
of additional data elements such as an analysis ‡ Percentage of suspected cases that were
of the sources and genotypes of all confirmed ODERUDWRU\GLVFDUGHG•
cases in the country in question. ‡ Percentage of confirmed cases with
LQIHFWLRQVRXUFHLGHQWLILHG•
 9DFFLQDWLRQFRYHUDJH These indicators should be monitored at
Vaccination coverage should be continuously all levels: district, provincial and national.
monitored by countries to enable the assessment While all are important, three indicators are
of population immunity. critical: 1) the proportion of suspected cases
with adequate investigation; 2) the proportion
‡ Vaccination coverage: vaccination of suspected cases with a blood specimen
coverage of both first routine measles dose collected within 28 days of rash onset or an
(MCV1) and second dose (MCV2, either epidemiologic link to a laboratory-confirmed
through routine or SIA coverage) case; and 3) the proportion of transmission
‡ Vaccination coverage marker: achieving chains with representative samples for viral
and maintaining at least 95% coverage isolation.
with both MCV1 and MCV2 in all districts
or their equivalent, and nationally.
9.3 Feedback
 ,QFLGHQFH
‡ Incidence: measles incidence per million Regular feedback to everyone involved in the
population per year should be used to surveillance system is important to ensure that
monitor progress towards elimination. sustainability and refinements to the system
The numerator should exclude measles are implemented as necessary. Feedback may
cases confirmed as imported;10 be given in writing or verbally during on-
‡ Incidence marker; site supervisory visits and during the periodic
‡ Achieving a measles incidence of zero surveillance review meetings. Feedback
confirmed measles cases per million includes providing surveillance participants
population per year, excluding cases with the following.
confirmed as imported. ‡ The number and location of reported
Other indicators are used for monitoring cases
measles/rubella surveillance performance. ‡ An assessment of the level of promptness
‡ 3HUFHQWDJHRIVXVSHFWHGFDVHVQRWLILHG” and accuracy of their surveillance reports
GD\VRIUDVKRQVHW• ‡ Information on the effectiveness of
vaccination and control activities
‡ Specific recommendations on how to
10
solve common problems
All import-related cases and sporadic or endemic measles
cases that are not imported should be included.

37
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

‡ Commendations for personnel doing to interested parties and to all partners. To


excellent work. encourage reporting, it is important to respond
Feedback can be provided effectively in to all reports with at least an acknowledgement
writing by sending weekly or monthly measles of the report.
surveillance bulletins to the reporting sites,

38
References

References
1. Measles fact sheet number 286. Geneva, World Health Organization, revised December
2009 (http://www.who.int/mediacentre/factsheets/fs286/en/print.html, accessed 24
May, 2010).
2. Immunization, vaccines and biologicals, WHO vaccine-preventable diseases: monitoring system - 2007
global summary. Geneva, World Health Organization, 2007.
3. Centers for Disease Control and Prevention. Progress in global measles control and mortality
reduction, 2000–2007. Morbidity and Mortality Weekly Report, 2008, 57:1303–1306.
4. Forty-fourth Session of the Regional Committee for the Eastern Mediterranean, Teheran,
Islamic Republic of Iran, 4 to 7 October 1997 (Resolutions available at http://www.emro.
who.int/governance/PDF/RC44_Resolutions.pdf, accessed 24 May 2010).
5. WHO position paper. Measles vaccine. Weekly Epidemiological Record, 2009, 84(35):349–360
(htt://www.who.int/wer, accessed 24 May, 2010).
6. Anonymous. Vaccination against measles: clinical trial of live measles vaccine given alone and
live vaccine proceeded by killed vaccine. Second report to the medical research council by
the measles vaccines committee. British Medical Journal 1968, 2:449–452.
7. Paunio M et al. IgG avidity to distinguish secondary from primary measles vaccination
failures: prospects for a more effective global measles elimination strategy. Expert Opinion on
Pharmacotherapy, 2003, 4:1215–1225.
8. WHO/UNICEF/IVACG Task Force. Vitamin A supplements: A guide to their use in the treatment
DQGSUHYHQWLRQRIYLWDPLQ$GHÀFLHQF\DQG[HURSKWKDOPLD. Second edition. Geneva, World Health
Organization, 1997.
9. WHO position paper. Rubella vaccines. Weekly Epidemiological Record. 2000, 75:161–172.
http://www.who.int/wer, accessed 24 May 2010.
10. WHO-recommended surveillance standard of measles (http://www.who.int/
immunization_monitoring/diseases/measles_surveillance, accessed 24 May 2010).
11. 0HDVOHVHOLPLQDWLRQÀHOGJXLGH. Washington, D.C. Pan American Health Organization, 2005,
Scientific and Technical Publication, Number 605.
12. WHO-recommended surveillance standard of rubella and congenital rubella syndrome
(http://www.who.int/immunization_monitoring/diseases/rubella_surveillance, accessed
24 May 2010).
13. 13. Guris D. Module on best practices for measles surveillance (WHO/V and B/01.43). Geneva:
World Health Organization, 2001.
14. Response to measles outbreaks in measles mortality reduction settings. Geneva, World Health
Organization, 2009 (http://www.who.int/immunization/documents/WHO_IVB_09.03/
en/print.html, accessed 24 May 2010).
15. Kabra SK, Lodha R, Hilton DJ. Antibiotics for preventing complications in children with
measles. Cochrane Database of Systematic Reviews 2008, Issue 3. Article Number: CD001477. DOI:
10.1002/14651858.CD001477.pub3.

39
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

16. WHO/UNICEF/IVACG Task Force. Vitamin A supplements: A guide to their use in the treatment
DQGSUHYHQWLRQRIYLWDPLQ$GHÀFLHQF\DQG[HURSKWKDOPLD. Second edition. Geneva, Wolrd Health
Organization, 1997.
17. Manual for the laboratory diagnosis of measles and rubella infection. Second edition. Geneva,
World Health Organization, 2007 (WHO/IVB/07.01).
18. Mosquera Model, M et al. Use of whole blood dried on filter paper for detection and
genotyping of measles virus. Journal of Virological Methods, 2004, 117:97–9.
19. Helfand, R.F et al. Comparative detection of measles and rubella IgM and IgG derived from
filter paper blood and serum samples. Journal of Virological Methods. 2001, 65:751–757.
20. Vyse AJ et al. Evolution of surveillance of measles, mumps, and rubella in England, and
Wales: providing the platform for evidence-based vaccination policy. Epidemiologic Reviews,
2002, 24:125–136.
21. Jin L et al. The role of RT-PCR assay of oral fluid for diagnosis and surveillance of measles,
mumps and rubella. Bulletin of the World Health Organization, 2002, 80:76–7.
22. Van Binnendijk RS et al. Evaluation of serological and virological tests in the diagnosis
of clinical and sub clinical measles virus infections during an outbreak of measles in The
Netherlands. Journal of Infectious Diseases, 2003, 188:898–903.

40
Annex 1

Annex 1

1RWLÀFDWLRQDQGFDVHLQYHVWLJDWLRQIRUPIRUPHDVOHVUXEHOOD
'DWHRIQRWLÀFDWLRQ____________________________ &DVH,'________ /________ /________ /
Province/territory _____________________________ 'DWHRIFDVHLQYHVWLJDWLRQ________ /________ /________
Reporting district ______________________________ ,QLWLDOGLDJQRVLV PHDVOHVUXEHOODRWKHUVSHFLI\
Reporting health facility _________________________
1DPH3DWLHQW·VIDWKHU·VQDPH ,VFDVHOLQNHGWRDQRWKHUFDVHRULQGH[FDVH"<HV1R8QN
---------------------------------/-------------------------------- if yes, write the ID of that case /_______ /_______ /_______
'DWHRI%LUWK______ /__________ /__________OR Is case outbreak associated? _______ <18QN ,I<HVJLYHWKH
$JH<HDUV________ Months ______ Days ______ outbreak ID _______
6H[________ M=Male F=Female Date seen at health facility ________ /________ /________
$GGUHVV+RXVH_______________________________ 'DWHRIRQVHWRIUDVK________ /________ /________
9LOODJH1HLJKERXUKRRG+RXVLQJ 6FKHPH ____________ 1RRIPHDVOHVUXEHOODYDFFLQHGRVHVUHFHLYHG________  8QN 
______________ Street no/name ________________ 9DFFLQDWLRQLQIRUPDWLRQREWDLQHGE\9DFFLQDWLRQFDUG+HDOWK
7RZQ&LW\__________ District __________________ VHUYLFHV3DUHQWV6HOI DGXOW 
'DWHRIODVWGRVHRIPHDVOHVYDFFLQH_____ /_____ /_____
'DWHRIODVWGRVHRIUXEHOODYDFFLQH_____ /_____ /_____
3UHJQDQF\VWDWXVRIZRPHQ___________________________

Outcome:
5HFRYHUHG&RPSOLFDWHG8QNQRZQ'LHG'DWHGHDWK______ /______ /______
+RVSLWDOL]HG<HV1R
&RPSOLFDWLRQV_____________________________________________________________________
'DWHQRWLÀHGWR'LVWULFW______ /______ /______

Possible Source of infection


'LGWKHSHUVRQKDYHFRQWDFWZLWKDQ\RQHVXVSHFWHGRIKDYLQJPHDVOHV²GD\VEHIRUHRQVHWRIUDVK"<HV1R8QN
If yes, who? _______________________ where? ___________________________________
:KHUHWKHUHDQ\VXVSHFWHGFDVHVRIPHDVOHVUXEHOODLQWKHDUHDEHIRUHWKLVFDVH"<HV1R8QN
'LGWKHSHUVRQWUDYHO²GD\VEHIRUHRQVHWRIUDVK"<HV1R8QN,I\HVZKHUH"____________________________
6RXUFHRILQIHFWLRQLGHQWLÀHG<HV1R8QN 2WKHUHSLGHPLRORJLFDOLPSRUWVWDWXVWUDYHOKLVWRU\ ________________
________________________________________________________________________

)LQDOFODVVLÀFDWLRQPHDVOHVUXEHOOD
&OLQLFDOO\FRQÀUPHG(SLGHPLRORJLFDOO\OLQNHGWRLPSRUWDWLRQ
/DERUDWRU\FRQÀUPHG9LURORJ\HYLGHQFHRILPSRUWDWLRQ
(SLGHPLRORJLFDOO\FRQÀUPHG8QNQRZQVRXUFH
'LVFDUGHGRWKHUFODVVLÀFDWLRQV
,QWHUQDWLRQDOLPSRUWDWLRQ
,QGLJHQRXV
'DWHRIÀQDOFODVVLÀFDWLRQ_________ /_________ /_________

Laboratory
'DWHEORRGVSHFLPHQFROOHFWHG___ /___ /___'DWHEORRGVSHFLPHQVHQWWRODERUDWRU\ ___ /___ /___ Date blood specimen
UHFHLYHGE\ODERUDWRU\___ /___ /___ &RQGLWLRQRIEORRGVSHFLPHQ$GHTXDWH,QDGHTXDWH8QN
Date measles serology results reported ___ /___ /___5HVXOWVRIPHDVOHVVHURORJ\SRVLWLYH1HJDWLYHQRWWHVWHG
LQGHWHUPLQDWH8QNQRZQ5HVXOWVRIGLIIHUHQWLDOVHURORJ\ PDNHVHSDUDWHYDULDEOHIRUHDFKGLVHDVH 3RVLWLYH1HJDWLYH
1RWWHVWHG,QGHWHUPLQDWH8QNQRZQ5XEHOODFRQÀUPHG<HV1R1RWWHVWHG
&ROOHFWLRQRIVSHFLPHQIRUYLUDOFXOWXUHLGHQWLÀFDWLRQ<HV1R8QN
6SHFLPHQW\SH________ 8ULQH 7KURDWVZDE 2UDOÁXLG'DWHVSHFLPHQ FXOWXUH 3&5UHFHLYHG___ /___ /___
5HVXOWVRIPHDVOHVYLUDOFXOWXUHLGHQWLÀFDWLRQ3RVLWLYH1HJDWLYH1RWWHVWHG8QN

Investigator: __________________________ Position: ________________________________________________


Signature: _________________________ Date: ______ /______ /_______

41
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

Annex 2

Weekly surveillance report


5HSRUWLQJXQLW________________________________________
'DWHVIURP____________ to ____________
1XPEHURIVXVSHFWHGPHDVOHVFDVHV_____
$WWDFKIRUPVRQDQ\FDVHLIQRFDVHVWRUHSRUWLQGLFDWH
1XPEHURIDFXWHÁDFFLGSDUDO\VLVFDVHV_____
$WWDFKIRUPVRQDQ\FDVHLIQRFDVHVWRUHSRUWLQGLFDWH
2WKHU_________________________________________________
RWKHUGHVLJQDWHGGLVHDVHRUFRQGLWLRQ
3HUVRQÀOOLQJRXWUHSRUW__________________________________
'DWH____________

42
Annex 3

Annex 3

Line-listing elements of data for measles reporting after


investigation
Measles surveillance data elements
Element of data Options

&RXQWU\ 6WDQGDUG1DPH

Province 6WDQGDUG1DPH

District 6WDQGDUG1DPH

Health formation 8UEDQ+85XUDO+88UEDQ+&5XUDO+&+RVSLWDO+HDOWKLQVXUDQFH

'DWHRIQRWLÀFDWLRQ ''00<<<<

Date of onset of rash ''00<<<<

EPI.ID EPID agreed by the country “Same as polio case coding”

1DPH

Age in years 1XPEHURI\HDUV]HURIRUFDVHVOHVVWKDQRQH\HDU

Age in months 1XPEHURIPRQWKV

*HQGHU 0DOH)HPDOH8QNQRZQ

1DWLRQDOLW\

Address

Date of investigation ''00<<<<

9DFFLQDWLRQZLWK0&9 %ODQNIRUXQNQRZQ

Date last vaccination ''00<<<<

Link with another measles case <HV1R

Link with another rubella case <HV1R

For travellers number of days of arrival 1XPEHURIGD\VDIWHU\RXUDUULYDO

Destination of travel

Date specimen collected ''00<<<<

Date specimen received at the laboratory ''00<<<<

Type of specimen 6HUXP'U\EORRG2UDOÁXLG8ULQH7KURDWVZDE6HUXPDQGXULQH


6HUXPDQGWKURDWVZDE2UDOÁXLGDQGXULQH2UDOÁXLGDQGWKURDW
swab

&RQGLWLRQRIVSHFLPHQDQGUHDVRQRILQDGHTXDF\IRU $GHTXDWH3RRUGXHWRGHOD\RIVSHFLPHQUHFHLYLQJ3RRUGXHWR
serology TXDQWLW\3RRUGXHWRFROGFKDLQ3RRUGXHWRGHOD\LQVSHFLPHQ
FROOHFWLRQ3RRUGXHWRRWKHUUHDVRQV

43
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

Measles surveillance data elements


Kit type for measles serology %UDQGRIDVVD\

Measles serology result ,J0YH,J0YH(TXLYRFDOQRWWHVWHG

Kit type for rubella serology %UDQGRIDVVD\

Rubella serology result ,J0YH,J0YH(TXLYRFDOQRWWHVWHG

Date result shared with EPI ''00<<<<

&DVHFODVVLÀFDWLRQ 0HDVOHVODERUDWRU\FRQÀUPHG0HDVOHV(3,OLQNHG0HDVOHVFOLQLFDOO\
GLDJQRVHG5XEHOODODERUDWRU\FRQÀUPHG5XEHOOD(3,OLQNHG'LVFDUGHG
FDVH9DFFLQHUHODWHGFDVH'RXEOHLQIHFWLRQ,PSRUWHGFDVH

Epidemiologic situation 6SRUDGLFFDVHFKDLQRIWUDQVPLVVLRQHSLGHPLFLPSRUWHGFDVH

If epidemic index case (3,,'&RGHRILQGH[FDVH´VKRXOGEHWKHVDPHLQGH[FDVHIRUWKH


whole chain of transmission”

Outcome of the case 5HFRYHUHGGLHGFRPSOLFDWLRQ

Type of complication Type the complication diagnosed

44
Annex 4

Annex 4

Congenital rubella syndrome case investigation form


,QIDQW·VLGHQWLÀFDWLRQ
1DPHRIFKLOG___________________________________________________________________________________
'DWHRIELUWK_______ / _______ / _______
6H[0)3ODFHLQIDQWGHOLYHUHG___________________________________________________________________
+RVSLWDOFOLQLFUHFRUGQXPEHU _______________________________________________________________________
1DPH RI PRWKHU ________________________________________________________________________________
$GGUHVV _______________________________________________________________________________________
______________________________________________________________________________________________

1RWLÀFDWLRQ
6RXUFH ________________________________________________________________________________________
'DWHRIQRWLÀFDWLRQ_______ / _______ / _______
1DPHRIUHIHUULQJKHDOWKZRUNHU_____________________________________________________________________
$GGUHVVRIUHIHUULQJKHDOWKZRUNHU ___________________________________________________________________
______________________________________________________________________________________________
7HOHSKRQH QXPEHU _______________________________________________________________________________

&OLQLFDOVLJQVDQGV\PSWRPV
Group (a)
&RQJHQLWDOKHDUWGLVHDVH<HV1R
,I \HV GHVFULEH __________________________________________________________________________________
_____________________________________________________________________________________________
&DWDUDFW V <HV1R
*ODXFRPD<HV1R
3LJPHQWDU\UHWLQRSDWK\<HV1R
+HDULQJLPSDLUPHQW<HV1R

Group (b)
3XUSXUD<HV1R
6SOHQRPHJDO\<HV1R

45
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

Annex 5

&DVHEDVHGPHDVOHVUHSRUWLQJHOHPHQWVWRWKH5HJLRQDO2IÀFH
 8VHFRXQWU\VWDQGDUGQDPH

2. 8VHORFDWLRQVWDQGDUGQDPHSURYLQFHGLVWULFWORFDOLW\YLOODJHHWF

 8QLTXHLGHQWLÀHULQVXUYHLOODQFHGDWDEDVHVDPHDVSROLR

 $JHLQ\HDUV OHVVWKDQRQH\HDUFRXQWVLQWKHFROXPQRI\HDUVDQGQXPEHURIPRQWKVUHJLVWHUHGLQDJHPRQWK

 *HQGHU 0DOHIHPDOHXQNQRZQ

 'DWHRIRQVHWRIUDVK GGPP\\\\

 1XPEHURIPHDVOHVYDFFLQDWLRQGRVHVOHDYHEODQNIRUXQNQRZQ]HURIRUXQYDFFLQDWHG

 'DWHRIODVWPHDVOHVYDFFLQDWLRQ GGPP\\\\

 (3,OLQNHGWRDFRQÀUPHGPHDVOHVFDVH <HV1R

 'DWHVSHFLPHQFROOHFWHG GGPP\\\\

 0HDVOHV,J0 HTXLYRFDOQRWWHVWHGXQNQRZQ

 5XEHOOD,J0 HTXLYRFDOQRWWHVWHGXQNQRZQ

 'DWHVSHFLPHQUHFHLYHGLQWKHODERUDWRU\ GGPP\\\\

 'DWHODERUDWRU\UHSRUWHGEDFNWR(3, GGPP\\\\

 &RQGLWLRQRIVSHFLPHQDGHTXDWHSRRU

 7\SHRIVSHFLPHQFROOHFWHG 6HUXPZKROHEORRG'ULHGEORRG%ORRGDQGXULQH%ORRGDQGWKURDWVZDE%ORRGDQG


QDVRSKDU\QJHDOVZDE
 )LQDOGLDJQRVLV PHDVOHVODERUDWRU\FRQÀUPHGPHDVOHV(3,OLQNHGPHDVOHVFOLQLFDOO\GLDJQRVHG
 UXEHOODODERUDWRU\FRQÀUPHGUXEHOOD(3,OLQNHGGLVFDUGHGFDVHYDFFLQHUHODWHGLPSRUWHG
 Lab-ID number

 0HDVOHVYLUXVLVRODWH <HV1R

 0HDVOHVJHQRW\SHGRQH <HV1R

22. 0HDVOHVJHQRW\SH $%%%&&''''''''''()***++

 5XEHOODYLUXVDVyODWH <HV1R

 5XEHOODJHQRW\SHGRQH <HV1R

 5XEHOODJHQRW\SH D%&'()J$%F

46
Annex 6

Annex 6

Laboratory request form for measles


&RXQWU\FRGH__________________ Province/territory __________________ Reporting District __________________
Reporting health facility __________________________'DWHVHQW_____ /_____ /_____
&DVH,' _____ /_____ /_____ /_____ /_____

3DWLHQW·VQDPH________________ )DWKHU·VQDPH_____________________ 6H[______0 PDOH) IHPDOH8N XQNQRZQ


$JH<HDUV_____________ Months _____________
$GGUHVV&RPSOHWH_______________________________________________________________________________
'DWHRIELUWK_____ /_____ /_____'DWHRIRQVHWRIUDVK _____ /_____ /_____

6QR6SHFLPHQ7\SH'DWHRIFROOHFWLRQ'DWHRIVKLSPHQW'DWHUHFHLYHGDWODERUDWRU\&RQGLWLRQ'DWHRIUHVXOW5HVXOW
%ORRG _____ /_____ /__________ _____ /_____ /_____ _____ /_____ /_____ _____ _____ /_____ /_____ ______
2. Throat __ /____ /_______ ___ /____ /______ ______ /_____ /________ _________ ___ /____ /___ ____________
2UDOÁXLG____ /____ /
8ULQH __ /____ /_______ ___ /____ /______ ______ /_____ /________ _________ ___ /____ /___ _____________
Suggestions from laboratory, for future sampling, if any______________________________________________________

5HVXOWVWREHVHQWWRVXUYHLOODQFHIRFDOSRLQWDWUHSRUWLQJVLWHDQGFRXQWU\PHDVOHVVXUYHLOODQFHFHOO
&RPSOHWHDGGUHVV________________________________________________________________________________
7HOHSKRQHQR__________________________________________________
)D[QXPEHU___________________________________________________

1DPHRIODERUDWRU\___________________________________________
3HUVRQUHFHLYHGVDPSOH_________________________________________

47
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

Annex 7

Final report of measles outbreak and control measures


Country: Province/State:
District/locality Town/City:
Indicate surrounding areas where there
are measles outbreaks if any?
Date of rash onset DD MM <<<< Date of rash onset DD MM <<<<
RIÀUVWFRQÀUPHG RIODVWFRQÀUPHG
case: case:
Number of cases by age in years
Age  ² ² ² ² ² ² ! Total
Suspected
&RQÀUPHG
Deaths
'RFXPHQWHGYDFFLQDWLRQKLVWRU\RIWKHFRQÀUPHGFDVHV District/Locality coverage
Age in 1RQ GRVH 2 doses GRVHV 8QNQRZQ Total Age in 0&9 0&9
<HDUV vaccinated <HDUV

²
²
²
²
²
²
!
Total
Immunization response to the outbreak
District/ Date immunization started Target age group Target population 9DFFLQDWLRQFRYHUDJH
&LW\QDPH DD MM <<<<

Laboratory investigation
District/ Date 1RVHUXP 1R/DE 1R/DE Date Oral 1R2UDO 1RWKURDW *HQRW\SH Date
&LW\QDPH serum sp. specimens FRQÀUPHG FRQÀUPHG ÁXLGRU ÁXLGVS swabs of the virus reported
collected measles rubella throat S. back
collected

Discriptive analysis of
outbreak origin
Discriptive control
activities
Discriptive follow-up
activities
,QYHVWLJDWRU·VQDPH Date of DD MM <<<<
report

48
Annex 8

Annex 8

Laboratory procedures for measles/rubella


1. &ROOHFWLQJDQGKDQGOLQJRIEORRGVSHFLPHQIRUVHURORJLFFRQÀUPDWLRQ
‡ &ROOHFWPOEORRGIRUDGXOWVDQGROGHUFKLOGUHQDQGPOIRULQIDQWVDQG\RXQJFKLOGUHQE\YHQLSXQFWXUHLQWR
DVWHULOHWXEHODEHOOHGZLWKSDWLHQWLGHQWLÀFDWLRQDQGFROOHFWLRQGDWH )LJXUH 
‡ )LOOLQFDVHLQYHVWLJDWLRQIRUPVFRPSOHWHO\7KUHHGDWHVDUHYHU\LPSRUWDQW
– Date of rash onset
– Date of collection of sample
– Date of last measles vaccination.
‡ To separate the serum from red cells, one of the following three methods described below can be employed.
To prevent bacterial over-growth, ensure that the serum is aseptically transferred to a sterile test tube.
‡ /HWWKHEORRGVLWDWDQDQJOHIRUDWOHDVWPLQXWHV ZLWKRXWVKDNLQJRUEHLQJGULYHQLQDYHKLFOH WKHQSRXU
off carefully or remove the serum by using Pasteur pipette to pour into a sterile test tube and label with
patient ID.
‡ ,IDUHIULJHUDWRULVDYDLODEOHSXWWKHVDPSOHLQDUHIULJHUDWRUIRU²KRXUVXQWLOWKHFORWUHWUDFWVWKHQSRXU
off the serum the next morning. Do not freeze whole blood.
‡ ,IDFHQWULIXJHLVDYDLODEOHOHWWKHEORRGVLWIRU²PLQXWHVWKHQFHQWULIXJHWKHVSHFLPHQDW530IRU
²PLQXWHVDQGSRXURIIWKHVHUXPLQWRVWHULOHWXEH

Courtesy of David Featherstone, World Health Organization.

Figure 1. Serum collection by venipuncture

2. Storage and shipment of serum specimens


‡ 6WRUHVHUXPDWƒ&²ƒ&XQWLOLWLVUHDG\IRUVKLSPHQW7KHVHUXPFDQEHVWRUHGLQWKHUHIULJHUDWRUIRUD
PD[LPXPRIGD\V6HUXPPXVWEHIUR]HQDWƒ&LILWLVJRLQJWREHVWRUHGIRUORQJHUSHULRGV
‡ Place specimens in plastic bags. Specimens from different patients should never be sealed in the same bag.
Place specimen form and investigation form in another plastic bag and tape to inner top of the specimen
transport box.
‡ ,IXVLQJLFHSDFNV WKHVHVKRXOGEHIUR]HQ SODFHLFHSDFNVDWWKHERWWRPRIWKHER[DQGDORQJWKHVLGHVSODFH
VDPSOHVLQWKHFHQWUHWKHQSODFHPRUHLFHSDFNVRQWRS:KHQVKLSSLQJDUUDQJHPHQWVDUHÀQDOL]HGLQIRUP
receiver of time and manner of transport.

49
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome

3. +DQGOLQJDQGWUDQVSRUWRIGULHGEORRGVSHFLPHQXVLQJWKHÀOWHUSDSHUPHWKRG
‡ )RUWKHFROOHFWLRQRIDEORRGVDPSOHXVLQJWKHÀOWHUSDSHU HJ:KDWPDQ6 61R PHWKRGDVNLQ
SXQFWXUHPD\EHSHUIRUPHGRQWKHÀQJHURUKHHO LQLQIDQWVDQGFKLOGUHQ )RUWKHÀQJHUWKHDUHDZLWK
RSWLPDOYDVFXODWLRQDQGORZHVWVHQVLWLYLW\LVWKHVLGHRIWKHÀQJHUWLSDERXWPPIURPWKHQDLOEHG7KH
PLGGOHDQGULQJÀQJHUDUHEHVW7KHSXOSRQWKHWLSRIWKHÀQJHUVKRXOGEHDYRLGHGDVLWLVYHU\VHQVLWLYH)RU
the heel the puncture should be performed on the lateral or medial edges of the heel rather than the centre
of the heel.
‡ /DEHOWKHÀOWHUSDSHUZLWKQHFHVVDU\LQIRUPDWLRQIRULGHQWLÀFDWLRQ7KHÀOWHUSDSHUVKRXOGEHLQDVWDQGDUG
IRUPDW²PPFLUFOHWRSODFHWKHEORRGGURSV )LJXUH 
‡ 0DNHVXUHWKHSDWLHQWVLWVFRPIRUWDEO\$EDE\VKRXOGEHKHOGJHQWO\EXWÀUPO\E\WKHSDUHQW)RU)LQJHU
SULFNWKHKDQGVKRXOGEHZDUPDQGUHOD[HG7KHSDWLHQW·VÀQJHUVVKRXOGEHVWUDLJKWEXWQRWWHQVH&OHDQWKH
puncture site with an alcohol wipe and allow drying.
‡ 8VHWKXPEWROLJKWO\SUHVVWKHÀQJHUIURPWKHWRSRIWKHNQXFNOHWRWKHWLS:LWKWKHWKXPE·VJHQWOH
SUHVVXUHDWWKHWLSRIWKHÀQJHUSODFHWKHODQFHWDWWKHVLGHRIWKHÀQJHUWLS3UHVVWKHODQFHWÀUPO\DJDLQVW
WKHÀQJHURUKHHODQGDOORZWKHWLSWRSHQHWUDWHWKHVNLQE\PP'LVSRVHWKHXVHGODQFHWLQWRDVKDUSV
container.
‡ :LSHDZD\WKHÀUVWGURSRIEORRGZLWKDFOHDQSLHFHRIGU\JDX]H$OORZRQHGURSWRIDOORQWRHDFKFLUFOHRI
WKHÀOWHUSDSHU)LOODWOHDVWWKUHHFLUFOHVDQGIRXULISRVVLEOH(QVXUHWKDWWKHEORRGVRDNVFRPSOHWHO\WKURXJK
the paper over the complete area of the circle. 'RQRWKROGWKHÀOWHUSDSHUDJDLQVWWKHSXQFWXUHVLWH )LJXUH 
‡ $OORZWKHÀOWHUSDSHUWRDLUGU\WKRURXJKO\ DWOHDVWPLQXWHV EHIRUHHQFORVLQJLQDEDJRUVWRULQJ'U\LQJ
stabilizes the IgM and reduces the chance of microbiological contamination.

Courtesy of David Featherstone, World Health Organization.

Figure 2. 'ULHGEORRGVDPSOLQJWHFKQLTXH

50
Annex 8

‡ Wrap each dried blotting paper in paper/foil/plastic or an envelope to prevent possible cross contamination.
6WRUHHDFKÀOWHUSDSHURXWRIVXQOLJKWSUHIHUDEO\LQVLGHDSODVWLF]LSEDJWRSURWHFWLWIURPGXVWDQGPRLVWXUH
6WRUHLISRVVLEOHLQDFRROSODFHDQGWUDQVSRUWWRWKHODERUDWRU\DVTXLFNO\DVSRVVLEOHXQGHUUHYHUVHFROG
chain. The dried serum is stable at room temperature and can be shipped in an envelope by mail within a
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4. Handling and transporting naso-pharyngeal swabs for viral isolation


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‡ The patient is asked to open the mouth wide and say “ah”. The tongue should be depressed with a spatula,
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cotton swabs to dislodge epithelial cells. The swab is then placed in a labelled viral transport tube ensuring
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both.

8VHRIWKHYLURFXOW® virus transport swab/medium

Transport
tube
Swab
Sponge
containing
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the back of the throat is
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tongue depressor if necessary.

Transfer swab to In the lab, break off the swab into


transport tube label a screw capped vial containing 2ml
and ship to lab on 9LUXVWUDQVSRUWPHGLXP 970 
ice. 8VHDSLSHWWHWRWUDQVIHUWKH
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to the vial.

Courtesy of David Featherstone, World Health Organization. Courtesy of Ruth Parry, World Health Organization.

Figure 3. 7HFKQLTXHRIQDVRSKDU\QJHDOVSHFLPHQ Figure 4. 7HFKQLTXHRIRUDOÁXLGVDPSOLQJ


collection

51

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