JRHS 2018; 18(3): e00418 JRHS Journal of Research in Health Sciences journal homepage: www.umsha.ac.ir/jrhs Original Article Monitoring of Surveillance Quality Indicators of Measles in Iranian Districts: Analysis of Measles Surveillance System 2014-2016 Seyed Mohsen Zahraei (MD, MPH)1, Abolfazl Mohammadbeigi (PhD)2*, Narges Mohammadsalehi (MSc)2, Azam Sabouri (MSc) 1, Sima Afrashteh (MSc)3, Shahram Arsang Jang (PhD)4, Hossein Ansari (PhD)5, Salman Khazaei (PhD)6 1 Center for Communicable Diseases Control, Ministry of Health and Medical Education, Tehran, Iran 2 Neurology and Neurosciences Research Center, Qom University of Medical Sciences, Qom, Iran 3 Vic-Chancellor for Public Health, Bushehr University of Medical Sciences, Bushehr, Iran 4 Research Center for Environmental Pollutants, Qom University of Medical Sciences, Qom, Iran 5 Health Promotion Research Center, Department of Epidemiology and Biostatistics, Zahedan University of Medical Sciences, Zahedan, Iran 6 Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran ARTICLE INFORMATION ABSTRACT Article history: Background: The elimination target for measles as an acute and contagious disease in Eastern Received: 05 May 2018 Mediterranean Region (EMR) and Iran is planned by high-quality surveillance. We aimed to monitor the Revised: 09 June 2018 surveillance quality indicators of measles by in all districts of Iran during 2014-16. Accepted: 27 June 2018 Study design: A cross-sectional study. Available online: 30 June 2018 Methods: Four quality surveillance indicators of measles including non measles discarded rate, percent Keywords: of suspected cases with adequate investigation, percent of adequate blood specimen collection and Elimination percent with timely availability of laboratory results were assessed in Iran. Surveillance data of measles were extracted from the measles surveillance system and the risk point score for each district was Iran calculated based on WHO Risk Assessment Tool by a function of four indicators. Measles Vaccination Results: Overall, 14312 suspected cases and 322 districts were assessed and the risk points of measles' quality surveillance showed that 92.8% of Iranian districts were categorized as low risk, 2.8% medium Surveillance risk, 0.62% high risk and 3.73% very high-risk category. The appropriate non measles discarded rate indicator was 87.3%. The percent of suspected cases with adequate investigation (more than 2 per * Correspondence: 100000 people) was 87.9%. Moreover, the average of percent adequate blood specimen collection and Abolfazl Mohammadbeigi (PhD) percent with timely availability of laboratory results was 85.16% and 85.71%, respectively in all Iranian Tel: +98 2537842228 districts. E-mail: [email protected] Conclusions: The surveillance quality indicators in Iran were good and higher than the WHO plans. Increasing the percentage of non-measles discarded rate could improve the poor quality in high risk and very high-risk districts. Citation: Zahraei SM, Mohammadbeigi A, Mohammadsalehi N, Sabouri A, AfrashtehS, Arsang Jang S, Ansari H, Khazaei S. Monitoring of Surveillance Quality Indicators of Measles in Iranian Districts: Analysis of Measles Surveillance System 2014-2016. J Res Health Sci. 2018; 18(3): e00418. Introduction easles is an acute and highly contagious respiratory accurate testing of specimens5-8. Based on national elimination disease 1, 2 that is the cause of serious illness, lifelong practices in Iran, the overall coverage of full vaccines complications and more than two million deaths immunization is 96.8% 9 and the vaccination coverage for first M 3, 4 annually worldwide . During 2000 to 2010, the estimated and second dose of MMR in under 5-yr-old children in suburb global measles mortality of measles decreased to 74% from area of big Iranian cities was estimated as 97.1% and 94.9% 535300 deaths to 139300 3. Measles is still left over as an respectively 9, 10 and SIAs in Iranian target population children important public health problem in Iran that is a member of the was estimated as 98.7%11. However, despite these Eastern Mediterranean Region (EMR) of WHO.1 However, the achievements, progress toward elimination goals has been elimination target for measles in EMR region planned for 2010 slowed and measles occurrence happened in some areas. as the interruption of endemic measles virus transmission for In 2012, WHO Regional Committees reaffirmed its more than one year by high quality surveillance1, 3. commitment to eliminate measles to interrupt endemic The programs for elimination of measles in Iran are measles virus transmission as rapidly as possible 12. To prevent including the two-stage of children immunization 12 and 18 future measles outbreaks a new tool was developed to assess months after birth, mass immunization of 5 to 25 yr old against district-level risk for measles outbreaks. The WHO measles measles/rubella at 2003, Supplementary Immunization programmatic risk assessment tool estimate the risk point of Activities (SIAs) in deprived and high risk areas and enhanced measles for each districts13-15. “Measles elimination programs high-quality case-based measles surveillance by timely and need to be monitored through the analysis of surveillance data 2 / 7 Surveillance quality indicators of Measles in Iran and performance indicators”16. Therefore, we aimed to it was calculated by the WHO measles programmatic risk monitor the surveillance quality indicators of measles by assessment tool. Then the overall risk of surveillance quality estimating and mapping the risk of measles outbreak in all of measles calculated and the tool assigned each district a risk districts of Iran based measles programmatic risk assessment category of low, medium, high, or very high and mapped it12,15. tool during 2014-16. To establish cut-off criteria for risk categories, a distribution was constructed consisting of all possible combinations of Methods scores from each indicator. Then, the risk scoring categories are defined by the 50th, 75th, and 90th percentiles of this In this cross-sectional study based on retrospective existing distribution19. The program delivery performance indicator for data, the indicators of measles surveillance during 2014-2016 each district was estimated by drop-out rate MCV1-MCV2 and were assessed in Iran and all districts of Iran were considered DPT1-MCV1. as the study subjects. Data Analysis Measles surveillance in Iran Data were analyzed in WHO Measles Programmatic Risk The measles surveillance in Iran is a robust communicable Assessment Tool that works under Excel and GIS software disease surveillance system supported by laws relating to (ver. 9.3). We used a later version of shapefile for Iran that mandatory reporting of all suspected measles cases contains 322 districts because the new updated shapefile for all immediately. The surveillance system of measles is districts of Iran did not found. Therefore, some new districts responsible for collecting and reporting surveillance data and (cities) separated recently, are merged with the prior districts. managed by a network of medical universities in Iran. WHO The risk point score for surveillance quality in each Iranian standard recommendations for measles surveillance used as district was calculated based on WHO Risk Assessment national guidelines for measles surveillance in elimination Tool18,20. phase and distributed to all health facilities to detect and report 7 all cases . Results Data Sources Overall, 14312 suspected cases were assessed and 22.1% We used from 4 different data sources including areas of (3165), 45.9% (6573) and 32% (4574) were registered from each Iranian district in Geographic Information System (GIS) 2014 to 2016, respectively. Overall, 322 districts in 31 shapefile, population census of 2016 for each district, provinces of Iran were assessed and the risk points of measles vaccination coverage for measles and Pentavalent during study outbreak were calculated based on four different surveillance years. Moreover, surveillance data of measles were extracted quality indicators. The appropriate non measles discarded rate from the measles surveillance system in Center for indicators were 87.3%, the percent of suspected cases with Communicable Diseases Control (CCDC) in Ministry of adequate investigation (more than 2 per 100000 people) was Health. All the suspected cases of measles with clinical 87.9%. Moreover, the average of percent adequate blood findings including fever, generalized maculopapular rash and specimen collection and percent with timely availability of either a cough, coryza or conjunctivitis17 that categorized as laboratory results was 85.16% and 85.71%, respectively in all Lab-Confirmed Measles, Epi-Linked Measles, clinically Iranian districts. Compatible Measles, Confirmed Rubella, Discarded and The surveillance quality in most districts (92.86%) of Iran Pending during 2014-2016. Moreover, 14 variables regarding is categorized as low risk. However, 9 districts (2.8%) were in to measles monitoring including year, province, reporting medium risk category. Two districts (0.62%) categorized as district, case id, final classification, age in years, age in high risk and 12 districts (3.73%) as very high-risk category. months, sex, place of residence, date of rash onset, vaccination Based on Figure 1 very high-risk districts included Jam in status, number of vaccine doses, date of notification, date of Bushehr, Varzaqan in Esat Azerbaijan, Eqlid, Mohr and