|Year : 2015 | Volume
| Issue : 3 | Page : 406-409
Measles outbreak investigation in Dwarahat block of District Almora, Uttarakhand
STM Hashmi1, AK Singh2, V Rawat3, M Kumar3, AK Mehra3, RK Singh4
1 Epidemiologist, Base Hospital, Almora, Uttarakhand, India
2 Additional Chief District Medical Officer, Base Hospital, Almora, Uttarakhand, India
3 Department of Microbiology, Government Medical College, Haldwani, Nainital, Uttarakhand, India
4 Department of Community Medicine, Government Medical College, Haldwani, Nainital, Uttarakhand, India
|Date of Submission||23-May-2014|
|Date of Acceptance||18-Sep-2014|
|Date of Web Publication||12-Jun-2015|
Department of Microbiology, Government Medical College, Haldwani, Nainital, Uttarakhand
Source of Support: None, Conflict of Interest: None
Background: We report an assessment of measles outbreak during the months of February 2014 to April 2014 in Dwarahat block of district Almora and the response mounted to it. Materials and Methods: An intensive door-to-door search to six measles affected villages in Dwarahat block of district Almora, covering a population of 2,408 was carried out to identify the cases of measles by a rapid response team (RRT). A total of ten blood samples were randomly collected for detecting IgM antibody against measles. For all cases, information on personal details, place of residence, time of onset and status of immunization were obtained. Results: Overall attack rate (AR) was 2.8%. AR among the population of age-group 0-16 was 7.2%. Statistically significant higher AR (16.26%) was seen for the age-group of 0-5 years as compare to 6-10 and 11-16 years of age (AR-8.71, relative risk-0.53, 95% confidence interval-0.32-0.88, P value-0.012 and AR-0.57%, relative risk-0.035, 95% confidence interval-0.00-0.14, P value-0.000, respectively). Males were affected more often than females 35 [59.2%] vs. 24 [40.8%]. Measles-related complications were seen in three children. No death was reported. Of the 10 samples, nine were positive for measles IgM antibodies by enzyme-linked immunosorbent assay (ELISA). Conclusion: The recognition of early warning signals, timely investigation and application of specific control measures can contain the outbreak. The unvaccinated or partially protected human beings serve as the reservoir of measles virus. Hence, there is a need for sero surveillance for measles in Uttarakhand and one catch up measles immunisation campaign to prevent future outbreak.
Keywords: Almora, attack rate, outbreak, measles
|How to cite this article:|
Hashmi S, Singh A K, Rawat V, Kumar M, Mehra A K, Singh R K. Measles outbreak investigation in Dwarahat block of District Almora, Uttarakhand. Indian J Med Microbiol 2015;33:406-9
|How to cite this URL:|
Hashmi S, Singh A K, Rawat V, Kumar M, Mehra A K, Singh R K. Measles outbreak investigation in Dwarahat block of District Almora, Uttarakhand. Indian J Med Microbiol [serial online] 2015 [cited 2019 Dec 16];33:406-9. Available from: http://www.ijmm.org/text.asp?2015/33/3/406/158567
| ~ Introduction|| |
Measles is a highly infectious and potentially fatal viral infection mainly affecting children. Immunization against measles directly contributes to the reduction of under-five child mortality and hence to the achievement of Millennium Development Goal number 4.  With the Introduction of measles vaccine in the National programme from 1985, which is given at 9 to 12 months of age, the disease burden has reduced. Actual vaccine effectiveness, under field conditions, is usually lower (60%).  In the backdrop of poor immunization coverage and persistence of multiple foci, there is heightened risk of the disease in an epidemic form in India. Investigating each outbreak to understand the epidemiology of the disease and its current status in the country is therefore necessary.
| ~ Materials and Methods|| |
We defined a case clinically by World Health Organization criteria as: The occurrence of a febrile rash with or without cough, coryza, conjunctivitis and lymphadenopathy in a resident of Dwarahat block since February 2014 to April 2014.
A rapid response team comprising of a medical officer, epidemiologist, pharmacist and anganwadi worker was constituted. No ethical committee review was indicated as this epidemiological investigation was conducted purely in the context of a public health response to an outbreak. An intensive door to door search in all the six villages (Rawalsera Badighoot, Rawari, Idasera, Naulakot and Kanalgaon) of Dwarahart Block, covering a population of 2,408 was carried out to identify the cases of measles by a rapid response team (RRT). For all cases, information on personal details (age and sex), place of residence, time of onset of illness and status of measles immunization was ascertained by interviewing the mothers and reviewing immunization card. From this information, incidence of acute measles by age and sex was calculated.
Symptomatic treatment was given to all cases of febrile illness along with two doses of vitamin-A solution at 24-hours interval and antibiotics were provided, where needed. Sera from ten random cases were tested for measles Immunoglobulin M (IgM) by enzyme-linked immunosorbent assay (ELISA) (Platelia TM Measles IgM, Biorad, France) At Govt. Medical College, Haldwani.
Parents and community were advised to practice isolation of cases. Special vaccination programme was started by conducting camps in all affected villages and supplementary doses were administered to all the children regardless of previous vaccination history or illness. In this plan, target age group was 9 months to 10-year-old children.
| ~ Results|| |
Out of 2,408 total population, 59 cases were identified with an overall attack rate (AR) of 2.45%. Whereas, AR among the population of age-group 0-16 was 7.2% (59/814). Age-specific AR in different villages is depicted in [Table 1]. The median age of the cases was 5 years. Statistically significant higher AR was seen in the age group of 0-5 years (16.26%) as compare to 6-10 years of age (AR-8.71, relative risk-0.53, 95% confidence interval-0.32-0.88, P value-0.012) and 11-16 years (AR-0.57%, relative risk-0.035, 95% confidence interval-0.00-0.14, P value-0.000). A case of 26-year-old female was excluded from calculation. [Table 2] The AR in male was higher (8.10%) as compared to female (6.26%); however, this difference was not statistically significant. [Table 3] Among the measles cases, 89.8% cases had received single dose of measles vaccine. Three children below 9 months of age had not received immunization and in three cases above 15 years (one 26 years old and two 16 years old) immunization status could not be ascertained. Measles-related complications pneumonia and diarrhoea were seen in three children. No death was reported. The number of cases peaked during 1 st and 3 rd week of March 2014 [Figure 1]. Nine of the ten samples were positive for measles IgM ELISA.
|Table 1: Age-specific attack rates in six villages of Dwarahart Block of Almora district, Uttarakhand |
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|Table 2: Overall age-specific attack rate in Dwarahart Block of Almora district, Uttarakhand |
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|Table 3: Sex-specific attack rate in Dwarahart Block of Almora district, Uttarakhand |
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| ~ Discussion|| |
Measles is rightly called as captain of killer team, especially in developing countries.  More than one-third of all measles deaths worldwide (around 56000 in 2011) are among children in India. 
Uttarakhand state comprises of 13 districts, which are divided in two region, ie Garhwal region (consist of seven districts) and Kumoun region consisting of six districts. Almora is one of the seven districts in Kumaon region of Uttarakhand. Villages-Rawalsera, Badighoot, Rawari, Idasera, Naulakot and Kanalgaon lies in Dwarahat Block of district Almora [Figure 2] and cover a population of 2,048.
A local community health worker and also local news paper reported a measles outbreak in the village Rawari and Badogoot of Dwarahat block of Almora on 7 th March 2014. The outbreak caused great concern to both the community and the Government and a RRT was constituted on 8 th March. Dwarahart block is 60 km from District headquarter Almora and caters a total population of 2,842. A visit to Rawari and Badogoot area on 10 th March 2014 revealed that a total of 22 cases of clinically suspected measles cases were reported in the first week of March 2014. Measles comes under regular surveillance of Integrated Disease Surveillance Programme (IDSP). In the preceding three calendar years (2013, 2012 and 2011), not a single clinically or laboratory confirmed case was reported from this region thereby suggesting an outbreak. More than five cases of clinical measles reported in a week in a block can be considered as outbreak as per the field guide 'Measles surveillance and outbreak investigation. (2005)'  further supports the evidence of outbreak. The outbreak spread to four other neighbouring villages named Rawalsera, Idasera, Naulakot and Kanalgaon of Dwarahat block.
Median age of the cases was 5 years, which was comparable to the previous outbreaks reported in India. ,,, In the present study, 3% of cases were below 9 months of age who had not received measles immunization and 92% were above 2 years of age who had received single dose of measles which is indicative of the accumulation of susceptible population. In Uttarakhand 2 nd dose of measles at 16-24 months has been initiated since 2011. Partially protected human beings serve as the reservoir of measles virus and this could be the reason for the outbreak. Hence, one catch up measles immunization campaign is required to prevent future outbreak and there is also need of sero-surveillance for measles in Uttarakhand. Males were affected more often than females 35 [59.2%] vs. 24 [40.8%] but this difference was not statistically significant like other studies. ,
About 15% of vaccinated children fail to develop immunity with the first dose, meaning that if only 80% are fully immunized, an outbreak is likely.  In our study, it was noticed that 93.9% (31/33) cases below 5 years had received primary immunization of measles, which may be an indication of vaccine failure or short lasting immune response as also reported by Vitek et al.  Defective practices of the cold chain system could affect the efficacy of the vaccine.
In the present outbreak, statistically significant higher AR was found between 0-5 years as compared to 6-10 years and 11-16 years [Table 2]. This was in contrast to Gupta et al.  where maximum cases were >5 years of age. Overall AR (2.8%) in our study was low as compared to other reported studies. ,,,,
Deaths from measles occur mainly due to complications of measles. Infants and young children, especially those who are malnourished, are at highest risk of dying. In this outbreak, no mortality was detected and only three children were diagnosed with measles-related complication like pneumonia and diarrhoea. This may be attributed to mild nature of disease, as also reported by Takhur et al.  However, the credit cannot be denied to district authorities for their proactive initiative to investigate the problem promptly and plug the gaps.
The measles outbreak occurred over a 8 weeks period from 22 February 2014 to 6 April 2014, no further cases were identified in the village over the subsequent 6 weeks. Availability of health services and better awareness resulted into low AR, fewer complications and no mortality. The outbreak provides a realistic description of how the district authorites detected and approached to the event. Part of the credit goes to the IDSP which currently being the only significant large scale surveillance effort in the state is paramount in raising awareness regarding surveillance of emerging and re-emerging diseases. Further, not only does IDSP provide training and equipment support to the staff but also ensures contingency funds for outbreak investigations, making it rather indispensable in disease monitoring at local levels.
| ~ Conclusion and Recommendation|| |
The recognition of early warning signals, timely investigation and application of specific control measures can contain an outbreak. In Uttarakhand, 2 nd dose of measles at 16-24 months has been initiated from 2011. There is further need of strengthening of existing routine immunization. Cold chain monitoring needs special attention. We recommend one catch-up immunization campaign for all children between 9 months to <10 years of age to avoid accumulation of susceptible children and there is also need of sero-surveillance for measles in Uttarakhand.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]