Measles Epidemiology and Elimination Status in Oman

Volume 1, Issue 3 Sultanate of Oman Ministry of Health

Jul-Sep 2017

Inside this issue:

Measles epidemiol- 1 ogy and elimination status in Oman

Public Health Sur- 7 veillance Round

The success story 9 of North Sharqiyah campaign Measles epidemiology and elimination status in Oman National ARI Sur- 11 Global situation veillance Q2 data he global eradication of smallpox that vened by WHO in 2010, it was stated that T was certified by WHA in 1980, the scien- global measles eradication is biologically, technically and operationally feasible. Q2 (Apr-Jun 2017) 12 – tific community was looking for another can- Communicable 15 didate vaccine preventable disease for the In the meantime several countries have Disease Surveil- feasibility of eradication. Poliomyelitis and adopted measles elimination (cessation of lance data measles looked promising then, but both endemic transmission) as their national goal have proved elusive so far. The framework and many were able to achieve it in the past developed for smallpox eradication was sub- decade. In May 2012, the Global Vaccine Editorial Board sequently applied for polio and later for the Action Plan (GVAP) for 2012–2020 was en- measles, rubella and the Congenital Rubella dorsed by the 194 WHO Member States at Executive Editor: Syndrome (CRS) eradication program. the 65th World Health Assembly that called Dr Seif Al Abri The scientific world is currently debating on for the elimination of measles and rubella in Director General, DGDSC at least 5 of the 6 WHO Regions by 2020. On the choice of measles ‘eradication’ and the intermediate goals of ‘mortality reduction’ September 27, 2016, the Pan American Editor: and ‘elimination’ on the grounds that main- Health Organization (PAHO) verified that Dr Shyam Bawikar taining elimination is a costly affair. However the Americas had eliminated endemic mea- in the global technical consultation, con- sles transmission. Board of Directors (Departments) Fig.1: Indigenous* measles cases and vaccine coverage in Oman: 1975– 2017 (Jun)

 Surveillance  Communicable Diseases  Central Public Health Laboratory  Infection Prevention and Control  Environment and Occu- pational Health

Contributors: Dr Shyam Bawikar Dr Padmamohan Kurup Dr Sultan Al Busaidi Dr Parag Shah

Dr Prakash Patel *Indigenous measles case is a case resulting from endemic transmission of the virus (i.e. virus present in Note: For details of laboratory confirmed the territory for ≥12 months) as confirmed by laboratory testing or epidemiological linkage cases from 1995-2017 (Jun) refer to Fig.2 Public Health Bulleti n

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Fig.2: Laboratory confirmed (IgM+) measles cases and rate per 100,000 population reported in Oman: 1995-2017 (Jun)

“Measles elimination Measles elimination goal is defined as the Registry’ was established in 2001. The last case Measles elimination is defined as the ab- of CRS on record was born in the year 2006. absence of endemic sence of endemic measles transmission in measles a defined geographical area (e.g., region or The Ministry of Health introduced a number of measures as a step towards elimination of transmission in a country) for ≥12 months in the presence of a well-performing system. measles, rubella and the CRS. A mass catch-up defined campaign was conducted in March 1994 tar- It means that countries should be able to geographical area geting children aged 9 months to 18 years irre- demonstrate to the review and certification spective of their previous immunization status. (e.g., region or commission, the evidence of a robust immun- A combined vaccine containing Measles and country) for ≥12 ization program with 2 doses of measles- rubella (MR) antigens was used in the house-to months in the containing vaccine (MCV2), a functional -house and the school campaign. Ninety four strong surveillance system and the absence presence of a well- percent of target population was covered. In of measles case/s due to local endemic geno- the same year a second dose of measles performing type in the past 3 years. The laboratory ca- (MCV2) and a first dose of rubella as MR vac- surveillance system.” pacity will be examined in parallel and the cine was introduced at 15 months in the child- classification of measles cases will also be hood immunization program. From April 1996 thoroughly scrutinized. a case-based surveillance was announced for Elimination milestones in Oman measles and rubella i.e. all the clinical cases Sultanate of Oman introduced the measles were subjected to serological test (IgM) for vaccine (MCV1) in EPI at 9 months since early both viruses for confirmation in the Central eighties. From the year 1990 the vaccination Public Health Laboratory. With these actions coverage for all antigens in the schedule re- the Ministry of Health had taken its first tenta- mained high (>95%). tive step towards the goal of elimination of measles and rubella infection in Oman. The country faced its last major simultaneous outbreak of measles and rubella in 1992-93. Subsequently the national goal of elimination Over 3,000 clinical measles cases were regis- of measles, rubella and the CRS was officially tered nationwide. In the following years (1993 endorsed from the year 2001. The fever and -94) a surge (>60 cases) of congenital rubella rash (F&R) surveillance was launched with se- syndrome (CRS) was noted in newborns due rological confirmation and epidemiological to maternal rubella infection during the out- investigation. Under this strategy all fever and break. The measles incidence dropped signifi- rash cases were presumed to be measles or cantly with MCV1 coverage consistently rubella unless otherwise proved by serology. above 95 percent since 1995. From the year 2004, the F&R surveillance program was further strengthened by developing The rubella incidence also declined due to the algorithm and national guidelines and also use of a combined vaccine. A ‘National CRS conducting training workshops to sensitize the Volume 1, Issue 3

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clinicians. In the early years the target of 2 cas- reported. The median duration of clusters was es of F&R cases per 100,000 population was 9 weeks. The lowest incidence was observed maintained and from 2004 onwards far ex- with 1 laboratory confirmed case in 2003. ceeded. The CPHL was recognized as a WHO-EMRO, The schedule of MCV in EPI was changed to 12 Regional Reference Laboratory (RRL) for mea- and 18 months from October 2006. A limited sles in the year 2004. Measles PCR and virus SIA campaign was conducted in 2007 targeting isolation, genotying and sequencing was intro- non-national students aged 15-18 years from duced in 2007. the private schools of Muscat governorate with Measles serosurvey 2016 high coverage (99.6%). A sample of anonymous residual sera from Postpartum rubella vaccination (single dose) Omani population were tested by quantitative was introduced in 2001. The campaign contin- assay for measles antibody titre (IgG) ued for the following years. The HCWs as a Sample size was proportional to population high-risk group was also vaccinated with MMR. “Subsequently the and stratified for age and gender. The repre- Description of measles clusters during sentative sample was assigned to hospital la- national goal of the elimination phase in Oman boratories in the Governorates in Oman. Re- sidual serum samples from inpatients/ elimination of With the catch-up campaign in March 1994, outpatients available in hospital laboratories measles, rubella introduction of MCV2 in 1994 and the case- was collected and tested. Age was the only based surveillance from April 1996, the num- information collected. The cut-off point for and the CRS was bers of measles cases started declining. How- immunity was measles specific IgG >200 IU/ml. Total 1,990 samples were tested, officially adopted Table-1: Lab-confirmed measles in Oman: 2000-2015 of these 1,666 (84%) were sero- from the year Governorate positive. Six samples had no de-

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Total Muscat 1 1 2 1 1 6 1 2 5 1 6 3 5 35 tectable antibody level (0.3%). 2001.” Dhofar 1 6 2 6 1 1 16 4 3 2 2 3 47 N Batinah 1 1 1 7 1 7 4 2 9 1 1 35 Assuming high vaccination cover- S Batinah 1 14 2 1 1 1 3 11 34 age the Geometric Mean titres Dakhliyah 3 1 1 2 1 13 1 22 (GMT) were plotted against fol- N Sharqiyah 6 1 2 2 1 12 S Sharqiyah 4 3 1 3 11 lowing age groups according to Dahirah 12 2 1 1 1 2 19 measles vaccine doses received Buraimi 2 2 Musandam 1 1 2 1. Not due for MCV1: <12 months Al Wustah 1 1 2. MCV1 only: 12-18 months Total 9 15 4 1 17 33 13 8 9 20 6 7 10 22 24 22 220 3. MCV1+MCV2: 18m-22 yrs ever small clusters continued to occur. In these 4. MCV1+Catch-up: 23-40yrs measles infection was confirmed in adults and 5. No vaccine: above 40yrs unvaccinated or partially vaccinated children. Description of clusters of 2016/2017 In a cluster in Mudaibi (2000) 6 cases were re- Oman witnessed large clusters of measles last- ported after investigations the index cases ing for several weeks during 2016 until June could be identified (Indian child), similarly in 2017. The event set off worries whether the another cluster from Buraimi (Dhahira) in 2001, gains of the past in the elimination efforts will 13 cases were reported from a school (Index be compromised. case-Yemeni boy). Total 178 laboratory confirmed cases of mea- A total of 220 confirmed cases were reported sles were reported in 2016 and 2017 (June) in in Oman from 2000 until 2015 comprising of 12 nine clusters with following details: clusters and isolated cases with unknown 2016 source of infection from the regions of Dhofar,  114 cases of measles were laboratory con- North and South Batinah, Muscat, and Dakhli- firmed with 3 distinct clusters yah. In the years – 2002, 2003, 2004, 2006, 2008, 2010, 2011 and 2012, NO clusters were  2 clusters in Southern Dhofar Governorate Public Health Bulleti n

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Table-2: Features of 9 measles clusters in Oman : 2016-17(Jun) Geno Cases Cases Code Cluster Period Year Total than those responsi- type 2016 2017 ble for earlier clus- DF-1 Dhofar-1 D8 Wk12-Wk30 2016 16 0 16 ters. SS-2 South Sharqiyah D4 Wk31-Wk48 2016 35 0 35  Buraimi cluster DF-3 Dhofar-3 B3 Wk36-Wk15 2016-17 53 37 90 (BU-#5i) an import- DF-4 Dhofar-4 B3* WK52-Wk04 2016-17 1 3 4 ed case (Asian) with BU-5i Buraimi - imported+related B3* Wk11-Wk12 2017 0 2 2 MT-6 Izki-Qurayat B3* Wk13-Wk17 2017 0 15 15 another associated MT-7 Muscat -Al Shaadi D8* Wk14-Wk17 2017 0 7 7 case MC-8 Muscat - Al Khod B3* Wk19-Wk25 2017 0 5 5  MT-#6,7 and 9 MT-9 Muscat + Dhofar D8* WK20-Wk22 2017 0 4 4 clusters occurred in * Phylogenetically distinct genotypes Total 105 73 178 multiple gover- DF-Dhofar, SS-South Sharqiyah, BU-Buraimi, MT-multi-governorate clusters, MC-Muscat norates with genotype D8 (DF-#1) and B3 (DF-#3) -  The transmission 16 and 53 cases) and 1 in South and North in the last cluster (MT-#9) ceased in Week “ Thus it may be Sharqiyah Governorates due to genotype #22 (Jun 2017) concluded that D4 (SS-#2) - 35 cases The interim final classification of laboratory  8 were isolated cases without clear link confirmed measles cases from Q1/Q2 of 2017 according to the with clusters or any source of infection is given in the following table. WHO criteria the  2 cases were imported (Thailand and PAK) Age distribution of measles cases elimination of  In all clusters and isolated cases the source Fig.3 shows of infection was unknown age distribu- Fig.3: Age distribution of measles status in measles cases 2016-17  69 (62%) cases were 12 months or less i.e. tion of mea- Oman has NOT not eligible for vaccination sles cases in the 9 clusters Final classification: 1,844 cases were inves- been compromised of 2016-2017. tigated under F&R surveillance in 2016, 27 Over half the (1.5%) were not tested, 167 were laboratory until this day.” cases were confirmed measles, 39 discarded as vaccine below the age related, 114 were confirmed. Source of infec- of 12 months tion for all was ‘unknown’, 2 cases imported. and ineligible 2017 (June) for MCV1.  The 2nd cluster (DF-#3) due to genotype B3 Second major in Dhofar governorate continued. It lasted age group from Wk36 (2016) to Wk15 (2017) and re- affected was 20 to 35 Thus three quarter of ported total 90 cases cases belonged to age group of under 1 year  Other 6 small clusters (DF-#4, BU-5i, MT- and 20-35 years. #6, MT-#7, MC-#8 and MT-#9) were noted from (Wk 52-2016- Wk 25-2017) Duration of clusters  The above 6 clusters were due to geno- The transmission and duration of the clusters types B3 and D8. However these genotypes is shown in Fig.3 and 5. The largest and the were distinctly different (Phylogenetic tree) longest cluster in 2016-17 in Dhofar (DF-#3) with 90 cases due to genotype B3 lasted for Table.3: Final classification of measles Q1/2 32 weeks. Thus it may be concluded that ac- Final classification (Q1/Q2 2017) # cording to the WHO criteria the elimination Lab-confirmed cases from clusters 73 of measles status in Oman has NOT been Imported (BU-5i) 4+1 5 compromised until this day. Import-Related (BU-5i) 1 1 Isolated cases 10 Why the measles clusters despite Discarded—Vaccine related 30 high quality surveillance and immun- Total laboratory confirmed measles cases 128 Volume 1, Issue 3

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Fig.4: Epicurve of measles clusters in Oman and the genotypes identified: 2016 - 2017 (Jun)

ization programs in Oman? vival rate since the early eighties “Maintain 95% Without vaccination, everyone gets measles.  No major outbreaks of measles since Sustaining measles elimination therefore 1992/93, only few small sporadic clus- herd immunity necessitates that each new birth cohort re- ters reported. Thus no opportunity for ceives 2 doses of MCV to ensure that at least natural boosting through SIAs 95% of individuals are immune. Despite this  Waning immunity could be more im- OR 5% of the birth cohorts remains susceptible portant than previously recognized and get accumulated over a period of time  We do not have clear laboratory evi- the measles virus and need periodic SIAs to maintain 95% herd dence on waning immunity to measles comes back with a immunity. vaccine OR vengeance to the measles virus comes back with a venge-  Reinfection of fully vaccinated individu- ance to discover the immunity gaps in the als with transmission of infection to oth- discover the country’s population ers might present a real risk in elimination settings where natural boosting is immunity gaps in The likely reasons and the scenarios are: no longer occurring  There are cohorts of young adults or the country’s  Some cases of measles in the age group adults who remain susceptible to mea- 2 to 20 yrs may have been due to rein- population.” sles in the community owing to inade- fection quate and incomplete reach in previous years  Once children leave school they are diffi-  Cohorts born before 1994 immunized cult to reach and vaccinating adults is with single dose of measles vaccine notoriously challenging  Vaccinated at 9 months (low response)  No immunization (SIAs) campaign/s  Primary vaccine non-responders was done in Oman in out-of-school population in the past  Unreached population: routine and catch-up campaign  Sustaining herd immunity while the other countries catch-up is now the greatest  Older generations immune through nat- challenge facing the countries that have ural infection are being replaced with interrupted endemic measles transmis- infants with lower levels of immunity sion who are born to mothers immune  through vaccination alone The non-Omani population comprises 45% of the population  Majority of pregnant mothers in  2016/17 have immunity to measles Majority of the non-Omani population from vaccine alone is from Asian countries where measles elimination program has not been es-  Oman’s birth cohort has increased from tablished or measles vaccine coverage 50,000 to 90,000 due to high child sur- is low Public Health Bulleti n

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Fig.5: Duration of 9 clusters in weeks and the genotypes identified: 2016-2017 (Jun)

tion of infants who were not due for the  No SIAs conducted in Oman after 1994 MCV1 (below 12 months of age). The geno- “Further measles i.e. 23 years. Hence herd immunity may types responsible for the clusters were D8, have been below the critical level D4 and B3. Of these the first two are preva- SIAs targeting In summary responding to outbreaks in coun- lent in Indian subcontinent while the 3rd is specific groups tries that have achieved or are close to from Yemen and North Africa. achieving, elimination of endemic transmis- The epidemiology of the measles infection in should be decided sion can be enormously expensive and dis- Oman suggests that there is no evidence of ruptive to the health services. specific circulating indigenous genotypes, on the basis of Recommended response although WHO EMRO considers B3 and D4 to be the indigenous local genotypes for Oman. analysis of measles  Recommended to plan and conduct a fol- Despite reporting several small clusters in the low-up campaign (SIA) with a single dose surveillance data past two decades. NONE of the imported of MMR in 2017 genotypes from Indian subcontinent (D4, D8) and the immunity  Close suggested immunity gap: target and Yemen/North Africa (B3) led to a sus- profile of the age group 20 to 35 years tained transmission within the country. The  It was also recommended that a ‘0’ dose of longest cluster so far lasted 32 weeks and was population through MCV should be offered to infants at 6-11 reported from Dhofar governorate due to months in Dhofar with for limited period genotype B3 (Sep 2016 to Jun 2017). The serosurveys .” until nationwide SIA campaign technology of genotyping has been helpful to  Further measles SIAs targeting specific differentiate various phylogenetically distinct groups should be decided on the basis of genotypes of the measles virus in Oman. analysis of measles surveillance data and Available scientific evidence does NOT sup- the immunity profile of the population port the view that the B3 and D4 are indige- through serosurveys to sustain the elimi- nous local genotypes in Oman. With a robust nation status childhood immunization program and a sen- The last word sitive surveillance system the Sultanate of Oman will continue to maintain the ‘measles The young adults and young infants repre- elimination status’ acquired in the late nine- sent the susceptible population. The clusters ties. In the years ahead the country proposes of measles in 2016 and 2017 resulted most to invite the process of verification by an ex- likely due to importation related source of ternal assessment team. infection. The MMR immunization campaign was con- Oman has 45% expatriate population mostly ducted Oman in Q3 and a full report will be from the Asian subcontinent. As it appears published in Q4 bulletin.

from the age distribution of the cases in 2016 and 2017 that the measles transmission was Ref.: David N Durrheim, Natasha S Crowcroft, The price of delaying measles eradication, Lancet Public Health, Vol 2, active in the young adult population who No. 3, e130–e131, March 2017 probably acted as vectors for a large propor- DOI: http://dx.doi.org/10.1016/S2468-2667(17)30026-9 Volume 1, Issue 3

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Public Health Surveillance Round (PHSR)

he innovative concept of ‘Public Surveillance and Control T Health Surveillance Round’ was Note: The public health round is a weekly launched FIRST time in Oman, MoH on epidemiological exercise. Therefore it is Wednesday the 18th of January 2017. The NOT intended to replace but to strength- central theme was to look at the surveil- en the surveillance and response func- lance data in real time on weekly basis and tions at the governorate as well as the to look for any early warning signs of an national level impending outbreak. Responsibilities The goal  Examine and analyse the information Detect public health emergencies in real and perform assessment of event (signal) time and plan an effective response to identify potential risk to public health. Objective Sources of information are as follows: “Public health 1. To function as “Epidemiological Intelli-  Reports through incident reporting gence” platform incorporating early de- chain surveillance rounds tection, risk identification, risk assess-  Disease and event notifications re- ment, facilitating timely response and ceived through the surveillance sys- (PHSR) are the tracking disease/event progression and tem uninterrupted trends in real time  Warning of diseases or other health 2. To document the occurrences of events hazards from other national and in- weekly and their interventions and the potential ternational sources (e.g. IHR alerts) epidemiological threats to human health in the Sultanate  Perform risk assessment through a struc- of Oman tured and transparent process by criteria review of the based checklist or by expert peer review surveillance data The PHSR logo with documentation  Bestow alert level to the event of public and information in health concern by general consensus and also to reset the alert levels for previous real time.” events  Advice effective response strategies or perform dynamic recalibration of response based on situation analysis of previously documented outbreaks  Review descriptive and analytical reports and advice on any additional data ele- ments to be collected  Disseminate the information on issues Scope and definition reviewed and discussed in the meeting Public health surveillance rounds (PHSR) The round #13 in session: May 3rd, 2017 are the uninterrupted weekly epidemiological review of the surveillance data and information undertaken by the office of the Directorate General for Disease Surveil- lance and Control through consensus of the designated team of experienced epidemiologists and public health professionals. In the governorate the responsibility of this activity lies with the Director for Disease Public Health Bulleti n

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to relevant stakeholders 1. Review of previous week report and  Enhance skills, quality improvement and follow-up actions capacity building through mentoring 2. Incident Command Chain report/s and scientific discussions  Foster and develop skills for planning 3. Weekly surveillance report (event-based public health interventions, defining and indicator-based surveillance) alert level, calibrate response based on 4. Other relevant public health event re- data updates during outbreaks or similar port/s from national/international sources situations 5. IHR alerts  Develop objective tools (e.g. checklist, process flow charts, uniform criteria etc.) that help in executing various tasks person or on the phone) and other tech- through a transparent process nical experts relevant to the subject under “Verification is an  Review the performance of the PHSR discussion essential step that periodically and introduce improve- Agenda format ments The reported event should be scrutinized consists of  Review the interim and final reports of and reviewed by the members on: confirming the outbreaks  Review the weekly epidemiological re- 1. Event description authenticity of the ports, monthly reports and annual re- 2. Verification of event 3. Risk stratification signal and its ports that are shared with other stakeholders (regional, national or interna- 4. Alert level characteristics. tional). 5. Responsible department/s or section/s 6. Specific recommendations Thus the verified  Review requests for public health research proposals 7. Next review (date) signal is then  Plan, process and review the scientific Risk assessment designated as an contents of the quarterly Public Health All data and information reviewed in the Bulletin of the DGDSC PHSR should preferably undergo initial “event” The process assessment such as event verification, validity check and the conformity check be- Venue: Meeting Room, DGDSC, Ministry fore review (See box) of Health Day: Every Wednesday— 08:00 to 09:00 am (Governorate: Every Monday)  Verification is an essential step that consists of confirming the authenticity Duration: 1 hour of the signal and its characteristics. Thus Coordination: Dept. of Surveillance the verified signal is then designated as an “event” Chair: Director General, DGDSC or desig-  Validity check is the active crosscheck- nated person. If none designated then Di- ing to assess whether the event is valid rector of Surveillance will be the chair across different sources of information Members: Epidemiologists, Public Health  Conformity check: Checking the event experts and Microbiologists/Virologists to see if it is pertinent to the surveil- from the departments under the DGDSC lance system or is relevant in the con- viz. Surveillance, Communicable diseases, text of Public Health surveillance Central Public Health Laboratory, Infection Prevention and Control, Environmental and Occupational Health, the governorate department representative if needed (in Volume 1, Issue 3

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The success story of North Sharqiyah campaign

he MMR campaign was the T first mass immunization campaign in Oman aimed at the out-of-school adult age group of 20 to 35 years. The campaign also targeted both Omani and non- Omani population of several na- tionalities with language barriers. These limitations were not con- ducive for achieving success. Moreover the Ministry of Health staff working at various levels of the health infrastructure had no previous experience of reaching “MMR campaign of and motivating an adult target group. preparing plan and during campaign 2017 was the first Despite these limitations the North Sharqi- yah Governorate successfully conducted  Wilayat focal points were designated mass th th the MMR campaign from 10 to 16 Sep- from DGHS and given responsibility of immunization tember 2017. preparing monitoring team and oversee micro-plan preparation and execution in campaign in Oman Before the campaign: The preparations all institutes. The age group of 25 to 35 years was select- aimed at the out-of-  Detailed micro-plan was prepared by ed as the target group for the MMR im- each health institute for static and out- school adult age munization campaign. The initial hurdles reach team. Bottom-up planning was were how to estimate the total number of group of 20 to 35 ensured. Outreach team planning was the target (beneficiaries) and thus measure carried out by the MoH staff in consulta- years.” the performance. Finally the target was tion with other ministries calculated based on the projected popula-  Total 75 static teams deployed at various tion estimates availa- health institutes including private hospi- ble in the Annual tals (200 staff). Total 46 outreach team Statistical Report, deployed for public gathering places and DG Planning, Minis- hard to reach areas. A vehicle with driver try of Health, 2015. was provided to all teams Specific institutional  All teams worked in morning and even- targets were further ing shifts. Night shift arranged for major estimated for each of hospitals the health facility in  Strong Community awareness campaign the governorate for done the nationals as well  Wilayat level campaign involving Wali, as for the non-nationals. Sheikhs, Shoura, community leaders  The Governorate target for North and all government sectors. Extensive Sharqiyah was estimated 100,832 use of social media (40,955 Omani and 59,877 non-Omani)  Special efforts done for expatriate mobi-  Various committees were formed at all lization by distribution of native lan- levels - at the Governorate, Wilayat and guage leaflets for non-Omani, public Health institution announcements, meeting with leaders  Regular meetings of all committees in of expatriate community, Government Public Health Bulleti n

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and NGO’s involvement and sponsor’s deployed as per requirements sensitization  Awareness and sensitization of the non-  Two daily report forms were prepared Omani (expatriate) clients ensuring their one at Governorate level for each team participation in the campaign was pre- (Team leader) and another for health sumed to be a constraint. Several ap- institute. (details included were shift and proaches were used and their coverage gender for detailed data analysis can) was mainly by the mobile teams. It was  Monitoring plan prepared and executed observed that several expatriate workers at health institute level registered in North Sharqiyah were staying outside the governorate hindering  Monitors from DGHS were deployed in the achievement of 100% target despite each Wilayat with daily feedback meet- special efforts including house-to-house ing of monitors by Wilayat focal points “Daily coverage visits in the major residential areas  Governorate control room was estab-  Daily coverage reports were prepared reports were lished. On daily basis coverage reports showing the progress of the campaign. received and analyzed prepared showing Detailed analysis of the data during the  Daily meetings at Governorate level for the progress of the campaign ensured corrective actions to Wilayat focal points to analyze coverage improve the coverage reports (by campaign. Detailed  Infectious waste management and gen- shifts, by team eral infection control practices during analysis of the data and by insti- the campaign was considered a chal- tute) with mid during the lenge. Awareness and training during -campaign the pre-campaign period ensured that campaign ensured corrective the staffs at all levels were aware and action to im- corrective actions compliant. The appropriate use of prove to improve the sharps container, avoiding needle stick The highlights of achievements injury and ensuring hand hygiene at eve- coverage.”  During the campaign the overall num- ry contact was emphasized bers vaccinated were 95,774 as against The success factors the target of 100,832 and thus achieving  Highest level of commitment witnessed 96% of the target at all the levels of staff  Total 100% Omani clients were vaccinat-  Extensive pre-campaign activities that ed whereas the coverage for non-Omani included community awareness cam- clients was 92%. paigns at Wilayat level. Strong efforts  55% of clients were vaccinated by static done to sensitize Omani as well as non- teams while 45% clients were vaccinated Omani population. Good use of social by the mobile teams during the first 7 media that aimed to motivate communi- days of the campaign ty for the acceptance of vaccination  Majority (70%) of Omani client were  Detailed micro-planning was done for covered by the static teams as against the mobile teams only 34% of the non-Omani clients  Adequate manpower was ensured by Major challenges engaging most of the HCWs including  Ensuring adequate manpower for all the retired staff for campaign including vol- static and the outreach team was a ma- unteers jor challenge. In the planning stage it  Hard-to-reach areas including mountain was ensured that enough manpower villages and the expatriate staying/ Volume 1, Issue 3

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National ARI Surveillance: Apr-Jun 2017

National Acute Respiratory Infections (ARI) Rate (Week 27, 2016 to Week 26, 2017)

Note: ARI rate is calculated as a ratio of admissions due to severe acute respiratory illness over total admissions at the sentinel site hospitals in Oman

Influenza viruses by subtypes: Week #14 to week #26, 2016 and 2017

Influenza viruses subtypes, 2017- Q2 Influenza viruses subtypes, 2016 - Q2 Public Health Bulleti n

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Communicable Disease Surveillance Data: By Governorates SECOND QUARTER Data: April—June 2017

North South Notified Communicable Diseases North South Al Muscat Dhofar Dakhliyah Sharqi- Sharqi- Dhahira Buraimi Musandam Total Batinah Batinah Wustah and Syndromes yah yah Group A Diseases Cholera 0 Yellow fever Never reported Plague Never reported Novel Influenza A virus Infection 0 Crimean-Congo Haemorrhagic Fever 1 1 Dengue fever 7 5 1 1 Pneumococcal invasive disease 1 1 Haemophilus influenzae type B 0 Meningococcal infection 0 Tuberculosis, pulmonary 57 17 6 13 6 6 1 3 4 1 Tuberculosis, extra pulmonary 16 3 3 3 1 2 2 2 Malaria 317 58 18 45 39 21 35 24 42 34 1 Rabies 0 Group A Syndromes Acute Flaccid Paralysis surveillance 10 2 2 3 2 1 Fever & Rash-Illness surveillance 1,026 200 52 204 214 147 47 50 85 27 Measles IgM pos. [Clinical cases] 32 [4] 17 [3] 4 [1] 9 1 1 Rubella IgM pos. [Clinical cases] 0 [1] 0 [1] Congenital Rubella Syndrome (CRS) 0 Acute Haemorrhagic Fever Syndrome 6 3 1 1 1 Coronavirus Respiratory Syndromes 0 Food Poisoning (Infectious origin) 76 6 14 11 12 24 7 2 Group B Diseases and Syndrome Acute Viral Hepatitis (Total) 760 15 133 128 13 2 133 326 4 1 3 2 Acute Viral Hepatitis A 428 10 34 102 34 245 1 1 1 Acute Viral Hepatitis B 13 1 5 1 1 4 1 Acute Viral Hepatitis C 21 2 19 Acute Viral Hepatitis D (in B pos) 0 Acute Viral Hepatitis E 3 1 1 1 Acute Viral Hepatitis unspecified 295 2 98 2 12 1 99 79 2 Typhoid fever 10 8 1 1 Pertussis 148 8 64 23 9 14 17 2 11 Brucellosis 103 91 2 1 2 2 5 Leishmaniasis cutaneous 2 1 1 Leishmaniasis visceral 0 Schistosomiasis, intestinal 0 HIV/AIDS 27 9 5 9 1 3 Mumps 428 40 34 95 58 68 47 33 42 7 1 3 Varicella 6,881 950 199 1502 1256 1658 421 446 225 106 53 65 Acute Encephalitis Syndrome 1 1 Other Meningitis Syndrome 25 21 2 1 1 Note: Quarterly data are provisional and Common note for all data tables: will be finalized in the annual report  The category of ‘Tuberculosis, pulmonary’ includes sputum positive and negative  HIV [AIDS] data are for nationals only  Measles and rubella clinically compatible cases [#] Volume 1, Issue 3

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Communicable Disease Surveillance Data: By Weeks (1 to 13) SECOND QUARTER Data: April—June 2017

Notified Communicable Diseases Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Total and Syndromes 14 15 16 17 18 19 20 21 22 23 24 25 26 Group A Diseases Cholera 0 Yellow fever Never reported Plague Never reported Novel Influenza A virus Infection 0 Crimean-Congo Haemorrhagic Fever 1 1 Dengue fever 7 1 2 3 1 Pneumococcal invasive disease 1 1 Haemophilus influenzae type B 0 Meningococcal infection 0 Tuberculosis, pulmonary 57 7 3 5 4 5 6 2 7 5 4 2 4 3 Tuberculosis, extra pulmonary 16 3 1 1 3 3 1 2 1 1 Malaria 317 11 17 16 21 34 18 26 37 34 23 26 35 19 Rabies 0 Group A Syndromes Acute Flaccid Paralysis surveillance 10 1 1 2 1 1 1 2 1 Fever & Rash-Illness surveillance 1,026 52 69 65 88 104 135 119 107 77 72 61 44 33 Measles IgM pos. [Clinical cases] 32 [4] 3 3 5 6 [2] 1 2 6 1 4 [1] [1] 1 Rubella IgM pos. [Clinical cases] [1] [1] Congenital Rubella Syndrome (CRS) 0 Acute Haemorrhagic Fever Syndrome 6 1 1 1 1 2 Coronavirus Respiratory Syndromes 0 Food Poisoning (Infectious origin) 76 13 9 3 10 6 12 9 5 8 1

Group B Diseases and Syndromes Acute Viral Hepatitis (Total) 760 94 94 83 79 82 78 49 34 46 35 36 26 24 Acute Viral Hepatitis A 428 59 66 58 45 50 43 26 8 22 15 19 11 6 Acute Viral Hepatitis B 13 1 3 1 1 2 3 1 1 Acute Viral Hepatitis C 21 1 1 13 1 1 1 1 2 Acute Viral Hepatitis D (in B pos) 0 Acute Viral Hepatitis E 3 1 1 1 Acute Viral Hepatitis unspecified 295 33 27 22 20 31 32 21 22 24 18 14 15 16 Typhoid fever 10 2 2 1 1 1 0 0 1 0 0 1 1 0 Pertussis 148 5 10 18 15 11 15 12 10 6 11 16 7 12 Brucellosis 103 10 6 6 12 13 8 5 6 10 10 4 10 3 Leishmaniasis cutaneous 2 1 1 Leishmaniasis visceral 0 Schistosomiasis, intestinal 0 HIV/AIDS 27 3 3 3 1 2 1 3 4 1 1 4 1 Mumps 428 43 46 43 30 46 46 28 30 28 19 22 26 21 Varicella 6,881 582 606 564 668 594 684 555 569 473 412 449 338 387 Acute Encephalitis Syndrome 1 1 Other Meningitis Syndrome 25 6 4 1 1 3 1 1 1 1 1 2 2 1 Public Health Bulleti n

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Communicable Disease Surveillance Data: Wilayat Distribution SECOND QUARTER Data: April—June 2017 Measles Rubella Menin. HIV TB Pulm Brucello- Governorate Wilayat AFP HepA HepB Malaria Pertussis CCHF IgM+ IgM+ infection [AIDS] Total TB sis Muscat 16 1 2 2 Mutrah 2 8 2 2 Muscat Bawsher 2 27 4 1 7 6 Seeb 1 1 [3] 1 19 2 5 7 6 Al Amerat 3 2 1 3 2 1 Qurayat 1 2 2 1 1 Salalah 2 4 [1] 20 1 14 50 5 7 4 41 Taqah 1 3 1 1 17 Dhofar Mirbat 3 10 Thumrait 4 1 6 Sadha 3 1 1 1 2 Rakhyut 1 1 9 Dhalkut Shaleem 1 1 4 Muqshan 1 Mazyoona 8 3 2 Sohar 2 9 3 20 9 2 3 3 1 Suwaiq 85 1 6 4+1(SB) 4 3 2 1(SB) North Saham 1 5 3 3 2 Batinah Shinas 2 5 4 1 1 1 Liwa 1 1 1 7 2 3 3 Khaburah 4 2 1 2 3 2 1 Rustaq 10 3 3 3 Barka 15 2 3 3 South Musanah 9 1 Batinah Nakhl 2 Wadi Maawil 1 Al Awabi 3 Nizwa 2 10 5 2 2 Samail 1 1 4 6 1 1 Dakhliyah Bahla 1 2 2 1 Izki 6 1 1 1 1 Adam 1 Al Hamra 2 1 Manah Bidbid 2 1 Ibra 1 13 1 Mudaibi 1 14 7 North Bidiyah 1 2 2 Sharqiyah Al Qabil 1 5 4 Dima Wa Al Tayeen 1 3 2 1 Wadi Bani Khalid 33 Sur 18 17 3 2 Jalan Bani Bu Ali 119 3 South Jalan Bani Bu Hassan 74 1 1 Sharqiyah Al Kamil Wa Al Wafi 33 3 1 1 Masirah 1 2 1 Ibri 1 [1] 4 37 11 6 4 Yankul 2 1 Dhahira Dhank 3 Buraimi 1 1 32 3 2 2 Mahda Buraimi Sunaina 1 Khasab Daba Al Baya 1 Musandam Bukha Madha Haima 1 1 1 (DK) 1 1 2 Duqum Al Wustah Mahoot 1 Al Jazer 3 TOTAL 10 32 [4] 0 [1] 0 428 13 317 148 27 73 57 103 1 Volume 1, Issue 3

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Communicable Disease Surveillance Data: Age Distribution SECOND QUARTER Data: April—June 2017

Notified Communicable Diseases Total <1 y 1-4 y 5-9 y 10-14 y 15-19 y 20-24 y 25-34 y 35-44 y ≥ 45 y and Syndromes Group A Diseases Cholera 0 Yellow fever Never reported Plague Never reported Novel Influenza A virus Infection 0 Crimean-Congo Haemorrhagic Fever 1 1 Dengue fever 7 1 3 3 Pneumococcal invasive disease 1 1 Haemophilus influenzae type B 0 Meningococcal infection 0 Tuberculosis, pulmonary 57 1 4 17 13 22 Tuberculosis, extra pulmonary 16 1 1 3 3 8 Malaria 317 1 1 4 73 172 44 22 Rabies 0 Group A Syndromes Acute Flaccid Paralysis surveillance 10 2 6 2 Fever & Rash-Illness surveillance 1,026 263 547 85 21 21 36 42 6 5 Measles IgM pos. [Clinical cases] 32 [4] 8 4 [2] 1 4 4 [1] 11 [1] Rubella IgM pos. [Clinical cases] 0 [1] [1] Congenital Rubella Syndrome (CRS) 0 Acute Haemorrhagic Fever Syndrome 6 1 2 2 1 Coronavirus Respiratory Syndromes 0 Food Poisoning (Infectious origin) 76 4 16 17 16 2 5 3 8 5 Group B Diseases and Syndromes Acute Viral Hepatitis (Total) 760 5 107 347 134 51 25 37 22 32 Acute Viral Hepatitis A 428 4 67 229 57 24 15 16 7 9 Acute Viral Hepatitis B 13 1 6 4 2 Acute Viral Hepatitis C 21 1 2 3 15 Acute Viral Hepatitis D (in B pos) 0 Acute Viral Hepatitis E 3 1 1 1 Acute Viral Hepatitis unspecified 295 1 40 118 76 25 9 12 8 6 Typhoid fever 10 1 1 1 1 2 3 1 Pertussis 148 122 15 6 4 1 Brucellosis 103 12 10 6 8 12 32 14 9 Leishmaniasis cutaneous 2 1 1 Leishmaniasis visceral 0 Schistosomiasis, intestinal 0 HIV/AIDS 27 1 1 3 9 9 4 Mumps 428 11 192 92 17 14 40 34 16 12 Varicella 6,881 490 1,209 2,308 1,155 511 423 579 168 38 Acute Encephalitis Syndrome 1 1 Other Meningitis Syndrome 25 5 3 4 1 6 2 4

Note: Leprosy and Dracunculiasis have been eliminated as a public health problem in Oman; while 'Zero' cases of diseases formerly under surveillance were reported in the second quarter of 2017. These are Anthrax, Diphtheria, Acute Poliomyelitis, Louse borne Typhus, Neonatal Tetanus and Lymphatic Filariasis. “The wisest mind has something yet to learn.”

Your contribution is valuable to us: Please write to us concerning your ideas and experiences, sharing them with a wider audience could benefit others, leading to new ideas, tech- niques and policies and helping to avoid struggling with problems oth- Sultanate of Oman ers have already solved. Ministry of Health

Note to contributors: Address for Communication: While submitting articles related to studies conducted in Oman, the Directorate General for Disease Surveillance and Control authors should attach a copy of the approval of ethical committee/ Ministry of Health HQ, PO Box 393, PC 100, research committee of the institution or the Regional Directorate. Muscat, Sultanate of Oman Your opinion matters to us. Any suggestions to improve the contents and the design of this bulletin will always be gratefully received. Any material from this bulletin may be reproduced, copied or distrib- Tel: +(968) 2235 7492 uted for non-commercial purposes provided the source is appropri- Fax: +(968) 2235 7541 ately quoted.

E-mail: [email protected] Editorial Board

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(Continued from page 10) Disclaimer working area was covered by the mobile teams. The outreach staff

The statements of facts and opinions expressed worked especially hard to reach the clients. Some of the mobile in the articles of this newsletter are solely those teams were working until late at night of the respective authors and or contributors.  The acceptance of community was satisfactory as a result of strong awareness campaign done at all levels  Very few rumours (e.g. infertility due to vaccine) encountered and corrective actions taken immediately by the active field team  No incidence of rejection of the vaccine by any client was noted  Intersectorial coordination was very high between all government and non-government sectors e.g. the construction companies, expatriate NGOs and hypermarkets and others actively participated Lessons learnt  Detailed micro-planning to reach the entire target population  Community awareness campaign  Intersectoral coordination with Government and the NGOs  Wilayat focal points for monitoring the campaign  Capacity building of the staff for the field level campaign  Post-campaign coverage survey  Standard national SOPs and guidelines for immunization campaign including the monitoring plan This quarterly Public Health news bulletin is published by the Directorate General,  Standardization of methods to estimate target age group Disease Surveillance and Control,  Electronic recording of client details using tablets Ministry of Health, Oman  Summarizing activities and preparing report