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					   Introduction of a rubella-
  containing vaccine into the
National Immunization Program
            Dr. Shyam Upreti
             EPI Chief, Nepal
   Sixth Meeting of SEAR EPI Managers
             New Delhi, India
              10-13 July 2007
                             Reporting Units for VPD Surveillance, Nepal




      Weekly Reporting Units = 340
      Active Surveillance Site and weekly reporting unit = 73
      Monthly Reporting Units = 3
      Total weekly reporting units= 413



Data as of 15 Jan 2007                                          WHO, Programme for Immunization Preventable Diseases (IPD)
                                   Suspected Measles Outbreak Cases, Nepal
                                            Jan 2003 to May 2007
                       1800                                                                                                                                       140


                       1600
                                                                                                                                                                  120

                       1400

                                                                      Measles Campaign                                                                            100
                       1200




                                                                                                  Phase III
  Measles like cases




                                                                                       Phase II




                                                                                                                                                                       Postive cases
                                                                          Phase I
                                                                                                                                                                  80
                       1000
                                                                                                                  Post-campaign peaks
                       800                                                                                           due to rubella                               60


                       600
                                                                                                                                                                  40

                       400

                                                                                                                                                                  20
                       200


                         0                                                                                                                                        0
                               J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M
                              03                       04                      05                      06                      07



                                                         Measles Like Cases         Measles IgM Positive        Rubella IgM Positive


Data as of 13 June 2007                                                                                       WHO, Programme for Immunization Preventable Diseases (IPD)
                           Distribution of Measles Like Cases, Nepal, 2006

                                                           Summary of Outbreaks (n=31)
                                                          Rubella Positive = 24
                                                          Measles Positive = 2
                                                          Measles + Rubella Positive = 1
                                                          Measles + Rubella Negative = 4




     Outbreak cases = 629 (31 outbreaks - 16 districts)
     Routine cases = 412
     Total cases = 1041
     Districts with measles-like cases = 48


Data as of 30 March 2007                                  WHO, Programme for Immunization Preventable Diseases (IPD)
                          Distribution of Measles Like Cases, Nepal, 2007

                                                           Summary of Outbreaks (n=14)
                                                          Measles Positive = 3
                                                          Rubella Positive = 6
                                                          Measles + Rubella Positive = 0
                                                          Measles + Rubella Negative = 1
                                                          Pending = 4




     Outbreak cases = 226 (14 outbreaks - 11 districts)
     Routine cases = 143
     Total cases = 369
     Districts with measles-like cases = 33


Data as of 05 June 2007                                   WHO, Programme for Immunization Preventable Diseases (IPD)
                               Rubella Cases by Age (Outbreak), 2003-2007


     350


     300


     250


     200


     150


     100


       50


         0
                     Under 1         1 to 4 yrs          5 to 9 yrs      10 to 14 yrs                 15+ yrs

                                                  2004   2005   2006   2007


Data as of 13 May 2007                                                 WHO, Programme for Immunization Preventable Diseases (IPD)
      Nepal’s EPI Multi-year Plan
    Objective 5: Expand VPDs Surveillance
Activities
 Study the disease burden of other VPDs (Hib,
  Rubella, Pheumo, Rota)
 Include surveillance of other Vaccine
  Preventable Diseases ( JE, Hib, Pneumococcal
  Pneumonia, Rotavirus)
 Train health staff on integrated surveillance
  activities
 Conduct a disease-burden study for
  Congenital Rubella Syndrome
          Nepal’s EPI Multi-year Plan
         Objective 6: Introduce New Vaccines

Activities
 Introduce        Rubella, MR, or MMR vaccine
 Introduce Hib vaccine
 Introduce JE vaccine:
       In routine immunization
       Through campaign in endemic districts
   Initiate Pneumococcal vaccine introduction
 Provide       rubella vaccine to WCBA
   2 Issues for introducing a
  rubella-containing vaccine


Risk   of increasing CRS cases
Cost
                 Pre-vaccine Phase
       Moderate to High Rubella Virus Transmission




                                  Passage

                                  Of Time




 Children & Adolescents                             Adults

Susceptible to rubella virus infection      Natural immunity
Acute rubella virus infection
                Post-vaccine Phase
           Lower Rubella Virus Transmission



                                  Passage

                                  Of Time




 Children & Adolescents                            Adults
Susceptible to rubella virus infection
                                            Vaccine & natural immunity
Vaccine-conferred immunity
Acute rubella virus infection
            Training &
   Consultation on CRS Disease
      Burden Determination
              December 2006

 WHO-SEARO
 WHO-IPD
 CDC


Disease burden determination options
    Acquired Rubella Infection
Nepal Context
 Measles surveillance shows that there is
  rubella virus circulating in Nepal.
 Data regarding among WCBA population
  is lacking.
    Acquired Rubella Infection
Possible activities
1. Case-based surveillance of all suspected
   measles cases.
2. Follow-up pregnant women possibly
   exposed to rubella during outbreaks for
   IgM testing.
3. Analysis of TORCH results.
Rubella Susceptibility in WCBA
Nepal Context
 Measles surveillance shows that there is
  rubella virus circulating in Nepal.
 Data regarding circulation among the 15+
  years population is lacking.
Rubella Susceptibility in WCBA
Proposed activity
1. TORCH testing in antenatal clinics
2. Sero-survey (cross-sectional or follow-
   up)
  i.    Convenience sample (large hospitals, anti-
        natal clinics)
  ii.   Population-based
       CRS Disease Burden
Nepal Context
 Only anecdotal evidence of CRS, i.e. no
  concrete data on CRS disease burden.
        CRS Disease Burden
Proposed activities – short term
1. Follow-up birth outcomes of pregnant women
   possibly exposed to rubella during the 2005-
   2006 outbreaks.
2. Retrospective data analysis at paediatric, eye,
   and cardiology units/hospitals.
3. Collect/analyze data on birth outcomes of
   rubella-infected pregnancies as identified by
   TORCH.
4. Determine prevalence of pigmentary
   retinopathy at schools for deaf children
       CRS Disease Burden
Proposed activities – long term
1. Conduct sentinel surveillance in
   paediatric, eye and cardiology
   units/hospitals in large cities.
2. Follow-up of birth outcomes of pregnant
   women in all rubella outbreaks.
3. Follow-up all TORCH rubella-positive
   pregnancies.
4. Include CRS in HMIS.
   Workshop on
CRS Control in Nepal
             15 June 2007
 Child Health Division & WHO-IPD

•1 Ophthalmologist
•1 Cardiologist
•1 Gynecologist/obstetrician
•2 Pediatricians
•1 Pathologist
Recommendation from Nepal CRS
      Control Workshop
1.        Continue surveillance to detect rubella
          virus circulation.
2.        Follow-up IgM and birth outcomes
          pregnant women exposed during rubella
          outbreaks.
3.        Conduct retrospective studies
     1.     Congenital cataracts: data abstraction from
            Eye Hospitals
     2.     Prevalence of pigmentary retinopathy in
            deaf students
             CRS Control
         Overall Proposed Activities

 Plan and implement rubella/CRS
  surveillance and disease burden studies.
 Set a national goal.
 Identify options for vaccine based on data.
 Determine cost implication for each option.
                Selected References
1.   WHO. Guidelines for surveillance of congenital rubella syndrome and
     rubella. Field Test Version, May 1999.
2.   Orenstein et al. Methods of assessing the impact of congenital rubella
     infection. Reviews of Infectious Diseases. 1985; Vol. 7, pages S22-S27.
3.   Best et al. Reducing the global burden of congenital rubella syndrome:
     report of the World Health Organization Steering Committee on Research
     Related to Measles and Rubella Vaccines and Vaccination, June 2004.
     Journal of Infectious Diseases. 2005; 192: 1890-1897.
4.   Bloom et al. Congenital rubella syndrome burden in Morocco: a rapid
     retrospective assessment. The Lancet. 2005; 365: 153-141.
5.   Dayan et al. Rubella and measles seroprevalence among women of
     childbearing age, Argentina, 2002. Epidemiology & Infection. 2005.
6.   Malakmadze et al. Development of a rubella vaccination strategy:
     contribution of a rubella susceptibility study of women of childbearing age in
     Kyrgyzstan, 2001. Clinical Infectious Diseases. 2004; 38:1780-3.
7.   Kyaw-Zin-Thant et al. Active surveillance for congenital rubella syndrome in
     Yangon, Myanmar. Bulletin of the World Health Organization. 2006;
     84(1):12-20.
8.   Hinman et al. Economic analyses of rubella and rubella vaccines: a global
     review. Bulletin of the World Health Organization. 2002; 80(4):264-270.
9.   Cutts et al. Control of rubella and congenital rubella syndrome (CRS) in
     developing countries, part 1: burden of disease from CRS. Bulletin of the
     World Health Organization. 1997; 75(1):55-68.

				
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