Escolar Documentos
Profissional Documentos
Cultura Documentos
:RUOG+HDOWK2UJDQL]DWLRQ5HJLRQDO2IÀFHIRUWKH(DVWHUQ0HGLWHUUDQHDQ
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome / World Health
2UJDQL]DWLRQ5HJLRQDO2IÀFHIRUWKH(DVWHUQ0HGLWHUUDQHDQ
S(0527HFKQLFDO3XEOLFDWLRQV6HULHV
,6%1
,6%1RQOLQH
,661
0HDVOHV HSLGHPLRORJ\ 5XEHOOD HSLGHPLRORJ\ 5XEHOOD 6\QGURPH &RQJHQLWDO HSLGHPLRORJ\
(SLGHPLRORJLF0HWKRGV*XLGHOLQH,7LWOH,,5HJLRQDO2IÀFHIRUWKH(DVWHUQ0HGLWHUUDQHDQ,,,6HULHV
1/0&ODVVLÀFDWLRQ:&
5. Surveillance activities and procedures for measles, rubella and CRS ....... 18
+HDOWKIDFLOLWLHV...........................................................................................................................................
'LVWULFWV.......................................................................................................................................................2
3URYLQFHV.....................................................................................................................................................2
1DWLRQDOOHYHO .............................................................................................................................................2
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.
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
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
11
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome
12
Establishing/strengthening surveillance systems
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
Adequate
specimen
0–28 days
Laboratory-
Rubella
FRQÀUPHG
Measles IgM IgM positive
rubella
negative
(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
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
21
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome
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
24
Outbreak investgations and control
25
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome
26
Outbreak investgations and control
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
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
Relative levels
in areas and among populations where a T cells
31
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome
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
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
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
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 ______________________________ ,QLWLDOGLDJQRVLVPHDVOHVUXEHOODRWKHUVSHFLI\
Reporting health facility _________________________
1DPH3DWLHQW·VIDWKHU·VQDPH ,VFDVHOLQNHGWRDQRWKHUFDVHRULQGH[FDVH"<HV 1R 8QN
---------------------------------/-------------------------------- 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 ________ /________ /________
$GGUHVV+RXVH_______________________________ 'DWHRIRQVHWRIUDVK________ /________ /________
9LOODJH1HLJKERXUKRRG+RXVLQJ 6FKHPH ____________ 1RRIPHDVOHVUXEHOODYDFFLQHGRVHVUHFHLYHG________ 8QN
______________ Street no/name ________________ 9DFFLQDWLRQLQIRUPDWLRQREWDLQHGE\9DFFLQDWLRQFDUG +HDOWK
7RZQ&LW\__________ District __________________ VHUYLFHV 3DUHQWV 6HOIDGXOW
'DWHRIODVWGRVHRIPHDVOHVYDFFLQH_____ /_____ /_____
'DWHRIODVWGRVHRIUXEHOODYDFFLQH_____ /_____ /_____
3UHJQDQF\VWDWXVRIZRPHQ___________________________
Outcome:
5HFRYHUHG &RPSOLFDWHG8QNQRZQ'LHG 'DWHGHDWK______ /______ /______
+RVSLWDOL]HG<HV 1R
&RPSOLFDWLRQV_____________________________________________________________________
'DWHQRWLÀHGWR'LVWULFW______ /______ /______
)LQDOFODVVLÀFDWLRQPHDVOHVUXEHOOD
&OLQLFDOO\FRQÀUPHG (SLGHPLRORJLFDOO\OLQNHGWRLPSRUWDWLRQ
/DERUDWRU\FRQÀUPHG 9LURORJ\HYLGHQFHRILPSRUWDWLRQ
(SLGHPLRORJLFDOO\FRQÀUPHG 8QNQRZQVRXUFH
'LVFDUGHGRWKHUFODVVLÀFDWLRQV
,QWHUQDWLRQDOLPSRUWDWLRQ
,QGLJHQRXV
'DWHRIÀQDOFODVVLÀFDWLRQ_________ /_________ /_________
Laboratory
'DWHEORRGVSHFLPHQFROOHFWHG___ /___ /___'DWHEORRGVSHFLPHQVHQWWRODERUDWRU\ ___ /___ /___ Date blood specimen
UHFHLYHGE\ODERUDWRU\___ /___ /___ &RQGLWLRQRIEORRGVSHFLPHQ$GHTXDWH ,QDGHTXDWH 8QN
Date measles serology results reported ___ /___ /___5HVXOWVRIPHDVOHVVHURORJ\SRVLWLYH 1HJDWLYH QRWWHVWHG
LQGHWHUPLQDWH 8QNQRZQ 5HVXOWVRIGLIIHUHQWLDOVHURORJ\PDNHVHSDUDWHYDULDEOHIRUHDFKGLVHDVH3RVLWLYH 1HJDWLYH
1RWWHVWHG ,QGHWHUPLQDWH 8QNQRZQ 5XEHOODFRQÀUPHG<HV 1R 1RWWHVWHG
&ROOHFWLRQRIVSHFLPHQIRUYLUDOFXOWXUHLGHQWLÀFDWLRQ<HV 1R 8QN
6SHFLPHQW\SH________ 8ULQH 7KURDWVZDE 2UDOÁXLG'DWHVSHFLPHQFXOWXUH3&5UHFHLYHG___ /___ /___
5HVXOWVRIPHDVOHVYLUDOFXOWXUHLGHQWLÀFDWLRQ3RVLWLYH 1HJDWLYH 1RWWHVWHG 8QN
41
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome
Annex 2
42
Annex 3
Annex 3
&RXQWU\ 6WDQGDUG1DPH
Province 6WDQGDUG1DPH
District 6WDQGDUG1DPH
'DWHRIQRWLÀFDWLRQ ''00<<<<
1DPH
*HQGHU 0DOH)HPDOH8QNQRZQ
1DWLRQDOLW\
Address
9DFFLQDWLRQZLWK0&9 %ODQNIRUXQNQRZQ
Destination of travel
&RQGLWLRQRIVSHFLPHQDQGUHDVRQRILQDGHTXDF\IRU $GHTXDWH3RRUGXHWRGHOD\RIVSHFLPHQUHFHLYLQJ3RRUGXHWR
serology TXDQWLW\3RRUGXHWRFROGFKDLQ3RRUGXHWRGHOD\LQVSHFLPHQ
FROOHFWLRQ3RRUGXHWRRWKHUUHDVRQV
43
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome
&DVHFODVVLÀFDWLRQ 0HDVOHVODERUDWRU\FRQÀUPHG0HDVOHV(3,OLQNHG0HDVOHVFOLQLFDOO\
GLDJQRVHG5XEHOODODERUDWRU\FRQÀUPHG5XEHOOD(3,OLQNHG'LVFDUGHG
FDVH9DFFLQHUHODWHGFDVH'RXEOHLQIHFWLRQ,PSRUWHGFDVH
44
Annex 4
Annex 4
1RWLÀFDWLRQ
6RXUFH ________________________________________________________________________________________
'DWHRIQRWLÀFDWLRQ_______ / _______ / _______
1DPHRIUHIHUULQJKHDOWKZRUNHU_____________________________________________________________________
$GGUHVVRIUHIHUULQJKHDOWKZRUNHU ___________________________________________________________________
______________________________________________________________________________________________
7HOHSKRQH QXPEHU _______________________________________________________________________________
&OLQLFDOVLJQVDQGV\PSWRPV
Group (a)
&RQJHQLWDOKHDUWGLVHDVH<HV 1R
,I \HV GHVFULEH __________________________________________________________________________________
_____________________________________________________________________________________________
&DWDUDFWV<HV 1R
*ODXFRPD<HV 1R
3LJPHQWDU\UHWLQRSDWK\<HV 1R
+HDULQJLPSDLUPHQW<HV 1R
Group (b)
3XUSXUD<HV 1R
6SOHQRPHJDO\<HV 1R
45
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome
Annex 5
&DVHEDVHGPHDVOHVUHSRUWLQJHOHPHQWVWRWKH5HJLRQDO2IÀFH
8VHFRXQWU\VWDQGDUGQDPH
2. 8VHORFDWLRQVWDQGDUGQDPHSURYLQFHGLVWULFWORFDOLW\YLOODJHHWF
8QLTXHLGHQWLÀHULQVXUYHLOODQFHGDWDEDVHVDPHDVSROLR
1XPEHURIPHDVOHVYDFFLQDWLRQGRVHVOHDYHEODQNIRUXQNQRZQ]HURIRUXQYDFFLQDWHG
&RQGLWLRQRIVSHFLPHQDGHTXDWHSRRU
46
Annex 6
Annex 6
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
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
49
Field guidelines for surveillance of measles, rubella and congenital rubella syndrome
3. +DQGOLQJDQGWUDQVSRUWRIGULHGEORRGVSHFLPHQXVLQJWKHÀOWHUSDSHUPHWKRG
)RUWKHFROOHFWLRQRIDEORRGVDPSOHXVLQJWKHÀOWHUSDSHUHJ:KDWPDQ6 61RPHWKRGDVNLQ
SXQFWXUHPD\EHSHUIRUPHGRQWKHÀQJHURUKHHOLQLQIDQWVDQGFKLOGUHQ)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\DWOHDVWPLQXWHVEHIRUHHQFORVLQJLQDEDJRUVWRULQJ'U\LQJ
stabilizes the IgM and reduces the chance of microbiological contamination.
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
ZHHN)RUDORQJHUSHULRGWKHGULHGVHUXPVKRXOGEHNHSWDW&XQWLOVKLSPHQW
Transport
tube
Swab
Sponge
containing
970 &ROOHFWWKURDWVZDEHQVXULQJ
the back of the throat is
9LURFXOWSDFNDJH YLJRURXVO\VZDEEHG8VH
tongue depressor if necessary.
Courtesy of David Featherstone, World Health Organization. Courtesy of Ruth Parry, World Health Organization.
51