Ahmed Z, Saeed A, Ahmed E, Ain QU, Hussain B, Sultan S, Muhammad K, Ghafoor T & Baig MA. Measles Outbreak Investigation in Nomadic Population Nasirabad, Balochistan, Pakistan February 2018. Global Biosecurity, 2020; 1(4). RESEARCH ARTICLES Measles Outbreak Investigation in Nomadic Population Nasirabad, Balochistan, Pakistan February 2018 Zubair Ahmed1, Abid Saeed1, Ehsan Ahmed1, Qurat ul Ain1, Barkat Hussain2, Saher Sultan2, Khair Muhammad1, Tamken Ghafoor1 & Mirza Amir Baig1 1 FELTP, 2 Government Abstract Introduction: On 14 February 2018, the District Health Officer of Nasirabad reported 16 suspected measles cases from the nomadic population of Dera Murad Jamali to the disease surveillance and response unit of Quetta and requested an investigation. A FELTP fellow was deputed by the Director of General Health Services, Balochistan to investigate the outbreak, evaluate risk factors and recommend control measures. Methodology: A purposive sampling technique was adopted and a case control study was planned and conducted. Case was defined as “acute onset of generalized maculopapular rash and fever with cough or coryza or conjunctivitis from 29 January to 20 February 2018 in a resident of Dera Murad Jamali”. Active case searches along with interviews were conducted through a semi structured questionnaire. Demographic, socioeconomic, clinical and epidemiological information was collected along with assessment of routine immunization. Five blood samples were sent for serology. Results: A total of 49 cases (AR= 0.17%), including five deaths (CFR=10.2%), were identified. Males, 61% (n=30), were more affected. The median age was three years (age range=1-10 years). The age-group 0-4 years, 69% (n=34), was most affected. The median age group of controls were four years (age range 1-11 years). Of the cases, 71% were unimmunized for any routine antigen while 32% of controls were unimmunized. Pneumonia, 42.8% (n=21), and diarrhea, 38.7% (n=19), were the most common complications. All five samples were positive for measles IgM. Significant statistical association was found between nomadic populations having zero routine doses of measles containing vaccines (MCV1) (OR 2.85; CI 1.83 – 4.42; p value <0.0021) and developing measles. Conclusion: Nomadic populations with low immunization was a probable cause of outbreak, resulting in the rapid spread of measles amongst susceptible individuals in the community. Laboratory tests confirmed the outbreak. As a control measure, measles mop-up vaccinations and six health education sessions were suggested and carried out. It was also recommended that proper outreach microplanning and regular pulse immunization should be adopted in future. Key words: Measles, outbreak, immunization, expanded program on immunization, nomadic population Introduction reducing measles deaths. From 2000 to 2016, Measles, a vaccine-preventable disease, is extremely vaccination against measles prevented 20.4 million contagious given that it can be spread via airborne deaths. Global measles deaths have decreased by 84% transmission.1 A susceptible person who has face-to- from an estimated 550,100 in 2000 to 89,780 in face contact with an infected person has a 90% 2016.5 likelihood of developing the disease.2 Measles is still The measles vaccination is highly effective, safe and common in many parts of the world, particularly in relatively cost-effective 6, and has interrupted measles countries with developing economies. Approximately transmission in most parts of the world,7 although 20 million cases are estimated to occur globally each high-risk areas remain in Africa and southern Asia. year, with 89,780 deaths from measles in 2016 – Population susceptibility to measles is dependent on mostly children under the age of 5 years, despite the the uptake of Measles 1 and Measles 2, vaccine availability of a safe and effective vaccine.3 effectiveness, immunity as a result of prior infection Measles is caused by a virus of the paramyxovirus and protection by maternal antibodies in infants. family and it is contracted through direct contact and Therefore, using these factors, it is possible to estimate through the air. Measles is a human disease and is not population susceptibility to measles using a well- known to occur in animals.4 Accelerated defined formula.8 immunization activities have had a major impact on Ahmed Z, Saeed A, Ahmed E, Ain QU, Hussain B, Sultan S, Muhammad K, Ghafoor T & Baig MA. Measles Outbreak Investigation in Nomadic Population Nasirabad, Balochistan, Pakistan February 2018. Global Biosecurity, 2020; 1(4). The Eastern Mediterranean Region has made In Pakistan, the Expended Program on substantial progress towards achieving measles Immunization was started in 1978, in which initially elimination and reducing the burden of Measles six vaccines were included, namely childhood disease. By 2008, measles deaths had decreased to tuberculosis, poliomyelitis, diphtheria, pertussis, 7000 deaths from 96,000 in 2000 - a reduction of tetanus and measles containing vaccine-1 (MCV-1), 93%. The number of confirmed measles cases while measles containing vaccine-2 (MCV-2) was decreased from about 88,000 in 1998 to 11,295 in added in 2009. The World Health Organization’s 20119. The World Health Organization (WHO)- statistics give more than 24,000 measles cases with UNICEF Global Immunization Vision and Strategy 300 deaths in Pakistan in the year 201711, out of which (GIVS) achieved a reduction in measles deaths by 90% 93 were from Balochistan 5; 12. The estimated MCV1 in 2010 compared to the year 2000 9; 10. During the coverage in Pakistan increased from 57% in 2000 to period 1998–2010, reported measles cases in the 76% in 2017, and the estimated MCV2 coverage Region decreased by 77%, from 89,478 cases in 1998 increased from 30% in 2009 to 45% in 2017, while to 10,072 in 2010. However, during 2011–2013, Balochistan remained the lowest in the country regional progress slowed and the number of reported coverage with MCV1 from 17% in 2009 to 33% in 2017 measles cases increased more than 2-fold to reach and MCV2 from 8% in 2009 to 34% in 201711. The 20,884 cases in 2013, with the occurrence of large MCV-1 coverage of the district was 22% in 2009 to outbreaks in several countries. Around 90% of the 43% in 2017 and MCV-2 coverage from 19% in 2009 to reported measles cases during the period 2011–2013 39% in 2017. The expanded program of immunization were from 5 countries: Afghanistan, Pakistan, schedule in the country is given in table below (Table Somalia, Sudan and Yemen. With this resurgence of 1). measles in some countries, the EMR’s target of measles elimination by 2015 is not likely to be achieved. Table 1: Routine Immunization Schedule in Pakistan Age of Child Vaccination At Birth OPV 0, BCG 6 Weeks OPV 1, PENTA 1, PCV 1, Rota Virus 1 10 Weeks OPV 2, PENTA 2, PCV 2, Rota Virus 2 14 Weeks OPV 3, PENTA 3, PCV 3, IPV 9 Months Measles 1 (MCV-1) 15 Months Measles 2 (MCV-2) Source: Expanded Program of Immunization Pakistan13 Background (Field Epidemiology and laboratory Training Program) This study was the account of the measles outbreak in fellow was deputed by Director General Health Services Nasirabad district in 2018. Nasirabad district is situated (DGHS) Balochistan on 17 February to investigate the at South East of the Balochistan province of Pakistan. outbreak, evaluate risk factors and recommend control The bordering districts are Sibi, Kachhi, Jhal Magsi, measures. Jaffarabad and Sohbat pur. The Population is highly mobile with seasonal migration for agriculture purposes. Research Question Pat Feeder Canal, a tributary from Sindh River serves the H0: There is no association between nomadic purpose of agriculture. According to censes 2017, the populations having zero routine immunizations (measles district has a population of 490,538 with an area of containing vaccine) and the development of a measles 3,387 km2 comprising of three Tehsils and 33 union outbreak. councils.14 H1: There is an association between nomadic On 16 February 2018, the District Health officer populations having zero routine immunizations (measles (DHO) of Nasirabad reported 16 suspected measles cases containing vaccine) and the development of a measles from the nomadic population of Dera Murad Jamali outbreak town to provincial disease surveillance and response unit Quetta and requested for an investigation. A FELTP Ahmed Z, Saeed A, Ahmed E, Ain QU, Hussain B, Sultan S, Muhammad K, Ghafoor T & Baig MA. Measles Outbreak Investigation in Nomadic Population Nasirabad, Balochistan, Pakistan February 2018. Global Biosecurity, 2020; 1(4). Methods and Materials community outside nomadic population were excluded. A purposive sampling technique was adopted and a Due to confined nomadic community and lab constraint case control study was planned and conducted. Matched only five samples were collected for Immunoglobulin M pairs for age and sex controls (1:2) were taken. Case was (IgM) serology. defined as “acute onset of generalized maculopapular rash and fever with one of the following: cough or coryza Results or conjunctivitis between 29 January to 20 February A total of 49 cases (overall AR= 0.17%) including five 2018 in a resident of nomadic population in Dera Murad deaths (Case Fatality Rate=10.2%) were identified. Sixty Jamali town”. Controls were selected against the cases percent (n=33) of cases from the total were detected from the same community. To understand the outbreak through the active search in community. The median age and the perspective of the community, a combined of the cases was three years with an age range one to ten meeting session with district administration and years, while the median age group of controls were four community members in the area was conducted. years with an age range one to eleven years. Among the Hospital records were reviewed and house to house cases, 61% (n=30) were males and 46% (n=19) were surveys were conducted using a pre structured females, while out of 98 controls, 67% (n=66) were males questionnaire.