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ORIGINAL ARTICLE
Year : 2021  |  Volume : 65  |  Issue : 5  |  Page : 23-28  

Measles outbreak investigation at Indo-Myanmar border, Longding District, Arunachal Pradesh, India, 2017


1 India Epidemic Intelligence Service Officer, National Centre for Disease Control, Delhi, India
2 Joint Director, Epidemiology Division, National Centre for Disease Control, Delhi, India
3 District Surveillance Officer, Integrated Disease Surveillance Programme, Ministry of Health and Family Welfare, Longding, Arunachal Pradesh, India
4 District Epidemiologist, Integrated Disease Surveillance Programme, Ministry of Health and Family Welfare, Longding, Arunachal Pradesh, India

Date of Submission19-Aug-2020
Date of Decision01-Dec-2020
Date of Acceptance10-Dec-2020
Date of Web Publication29-Jan-2021

Correspondence Address:
Kevisetuo Anthony Dzeyie
A-46, Second Floor, South Extension-2, New Delhi - 110 049
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_1067_20

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   Abstract 


Background: On May 23, 2017, the health authorities in Longding district, Arunachal Pradesh, India, reported four suspected measles-related deaths in Konsa village, a remote village on the Indo-Myanmar border. Objective: We investigated to describe the epidemiology of the outbreak and identify associated risk factors. Methods: We defined a measles case as fever and maculopapular rash with cough, coryza, or conjunctivitis in a village of Longding district resident from March 1 to June 18, 2017. In Konsa village, we conducted a retrospective cohort study of children ≤5 years. We calculated attack rate (AR), case fatality rate (CFR), measles-containing vaccine first dose (MCV1) and Vitamin A coverage, risk ratio (RR), and vaccine efficacy. We collected samples for laboratory confirmation. We conducted a routine immunization system evaluation at multiple levels of Longding district. Results: We identified 75 suspected cases (56% females) for a Konsa village-specific AR of 86% (75/87) among children ≤5 years; the median age was 36 months; CFR was 7% (5/75); all deaths unvaccinated; none received Vitamin A. Coverage for MCV1 was 9.2% (6/65) and Vitamin A 4.6% (3/65). No MCV1 (RR = 7.3, 95% confidence interval [CI] = 1.3–53) and participation in a recent local festival (RR = 5.3, 95% CI = 1.5–18.5) were associated with illness. MCV vaccine efficacy was 100%. Of 17 cases, 13 tested positive for measles. The local health facility had neither staff nor immunization microplans. Conclusions: This outbreak was likely due to low MCV1 and Vitamin A coverage due to poor health-care access. The investigation led to a district measles catch-up campaign and resumption of regular immunization.

Keywords: Measles, outbreak, risk factors, vaccination, Vitamin A


How to cite this article:
Dzeyie KA, Lowang D, Dikid T, Wangsu W, Tamir T, Working Group*. Measles outbreak investigation at Indo-Myanmar border, Longding District, Arunachal Pradesh, India, 2017. Indian J Public Health 2021;65, Suppl S1:23-8

How to cite this URL:
Dzeyie KA, Lowang D, Dikid T, Wangsu W, Tamir T, Working Group*. Measles outbreak investigation at Indo-Myanmar border, Longding District, Arunachal Pradesh, India, 2017. Indian J Public Health [serial online] 2021 [cited 2021 Feb 28];65, Suppl S1:23-8. Available from: https://www.ijph.in/text.asp?2021/65/5/23/308316

Working Group: L. Jampa, State Surveillance Officer, Arunachal Pradesh; Pradeep Khasnobis, Joint Director, Integrated Disease Surveillance Programme, Delhi; Biswajyoti Borkakoty, Scientist, Regional Medical Research Centre, Dibrugarh; Dipankar Biswas, Scientist, Regional Medical Research Centre, Dibrugarh, Assam; Purva Pankaj Sarkate, Deputy Director, Microbiology Division, National Centre for Disease Control; Charu Prakash, Joint Director, Microbiology Division, National Centre for Disease Control; Ekta Saroha, Public Health Specialist, US Centers for Disease Control, India Country Office; Rajesh Yadav, Public Health Specialist, US Centers for Disease Control, India Country Office; Samir V. Sodha, Resident Advisor, US Centers for Disease Control and Prevention; A. C. Dhariwal, Director, National Centre for Disease Control, Delhi, India





   Introduction Top


Measles is targeted for elimination in five World Health Organization (WHO) regions, including the South-East Asia Region (SEAR), by 2020. In 2018, India accounted for 21% (68,841/326,045) of global and 83% (68,841/82,929) of SEAR's reported measles cases.[1] Despite India's 2023 measles elimination goals,[2] there were still 931 suspected measles outbreaks reported in India in 2018 that resulted in 18,108 cases.[3] The 2015–2016 National Family Health Survey-4 reported coverage for the first dose of measles-containing vaccine (MCV1) in India as 81%, with large variability (50%–96%) between states. The government of India is committed to achieve the measles elimination target by improving measles vaccination coverage through routine immunization (RI), special immunization campaigns like Mission Indradhanush, and Measles-Rubella campaigns.[4],[5] In India, where vaccines are provided free of cost to beneficiaries, the RI program provides two doses of MCV: MCV1 at 9–12 months and the second dose of MCV given at 16–24 months.

Arunachal Pradesh is a hilly state situated in the north-eastern part of India, sharing borders with China and Myanmar. In 2015, Arunachal Pradesh had only 55% MCV1 coverage.[6] Longding district in Arunachal Pradesh is characterized by difficult terrain and hard-to-reach areas bordering Myanmar. Measles outbreaks have been reported in the Indo-Myanmar border region on several occasions through the Integrated Disease Surveillance Programme (IDSP). For India to achieve measles elimination, it is necessary to understand the reasons for low vaccination coverage in states such as Arunachal Pradesh by conducting field investigations.

On May 23, 2017, four suspected measles-related deaths were reported from Konsa village. Konsa village is a small, remote village of the Pongchau subdistrict or “block” in Longding district in Arunachal Pradesh, situated at the border of the Indian Nagaland state and Myanmar [Figure 1]. The Longding District Surveillance Unit of the IDSP initiated the investigation on May 25, 2017. Upon finding 13 suspected measles cases with 5 deaths, the National Centre for Disease Control (NCDC) deployed four officers, including two India Epidemic Intelligence Service (EIS) officers, to join the investigation. In this report, we describe the investigation and epidemiology of the outbreak, risk factors associated with illness found during the investigation, and recommendations on control and prevention measures.
Figure 1: Measles outbreak location, Longding district, Arunachal Pradesh, India, 2017.

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   Materials and Methods Top


Case finding

We defined a suspected case of measles as fever and maculopapular rash with either cough, coryza, or conjunctivitis in a resident of any one of the Longding district villages – Konsa village, Konnu village, Niausa village, and Longding village from March 1, 2017, to June 18, 2017. A confirmed case was defined as a suspect case with the detection of measles-specific immunoglobulin M (IgM) antibodies by enzyme-linked immunosorbent assay (ELISA) or measles virus by polymerase chain reaction (PCR). We searched for cases by reviewing inpatient and outpatient hospital records at Longding District Hospital and the Community Health Centre of Pongchau subdistrict, reviewing health outreach program reports from Konsa village and Konnu village, and conducting a house-to-house survey at Konsa village using a modified WHO India measles outbreak investigation form (VPDOB003).[7] We interviewed the family members of suspected cases who had died regarding their relative's clinical history. We defined a measles death as the death of a case within 1 month of illness onset.

Retrospective cohort study of Konsa village

We conducted a retrospective cohort study of Konsa village (109 houses, population 764) to assess vaccine coverage and efficacy and to determine risk factors for illness. We defined the cohort as children aged ≤5 years living in Konsa village from March 1, 2017, to June 20, 2017, among whom we assessed MCV coverage status based on data on MCV1-eligible children aged 12–60 months. We conducted a house-to-house survey using a semi-structured questionnaire that collected information on sociodemographics, clinical history, complications, vaccination status, and possible risk factors, including no vaccination against measles, attending shared village exposure locations, maternal education and employment, female child, and family monthly income <2000 INR. If we found any locked/unoccupied houses at the time of the survey, we revisited them one more time on that same day. We verified vaccination status by abstracting vaccination card registries. If the vaccination card was not available, we assessed vaccination status by maternal recall.

Occurrences of measles cases by exposure categories were noted.

Data analysis

We analyzed data using MS Excel and Epi Info software version 7.2 of US Centers for Disease Control and Prevention, Atlanta. We calculated the attack rate (AR), case fatality rate (CFR), vaccine coverage, vaccine effectiveness, and risk ratio (RR) with 95% confidence intervals (CIs) for risk factors. We calculated MCV effectiveness as: AR among unvaccinated minus AR among vaccinated divided by AR among unvaccinated multiplied by 100.[8],[9]

Laboratory investigation

The investigation team collected serum samples and nasopharyngeal swab samples from June 6–8, 2017, in Konsa village beyond the recommended regular five samples collected during measles outbreak investigations. If rash onset occurred 6–28 days before the sample collection date, we collected only a serum sample from suspected cases. If rash onset occurred <5 days before sample collection date, we collected only nasopharyngeal swabs from suspected cases. If rash onset occurred exactly 5 days before the sample collection date, we collected both a serum and nasopharyngeal swab. All serum samples were sent to the NCDC National Measles Laboratory for testing of measles-specific IgM by ELISA testing. All nasopharyngeal samples were sent in viral transport media to the Regional Medical Research Centre laboratory at the Indian Council of Medical Research facility in Dibrugarh, Assam state, for the measles virus by PCR testing and virus genotyping.

Routine immunization system evaluation

Guided by the retrospective cohort study result, in June 2017, we reviewed selected characteristics of the RI system and compared them against the Indian Public Health Standards sanctioned for community health centers to identify health system-related reasons for the outbreak. We assessed human resources, availability of RI microplanning, vaccine supply numbers, cold chain capacity, and logistics at multiple levels including at the subcenter (health outpost), the community health center (subdistrict health facility), and the district hospital based on the guidelines for RI by the Government of India.[10],[11] We gathered information by conducting interviews of health workers, using an observation checklist, and reviewing the immunization activity records of the last 6 months.

Ethical considerations

The investigation was a public health response to an outbreak as part of the India EIS Program, undertaken with the purpose to identify the source of spread for immediate control of outbreak and intended for the benefit of the community at large. Ethical approval is not applicable as part of public health response. The investigation did not involve any human laboratory sample collection for research purposes, and there were no invasive investigations or medical interventions/experiments. All Government of India ethical principles and guidelines were adopted during the outbreak response: the investigation was aimed at achieving public good (beneficence) and collective welfare (solidarity); no harm was done to any individual (nonmaleficence); fair, honest, and transparent (accountability and transparency); and participants' data were de-identified before analysis (confidentiality).


   Results Top


Descriptive epidemiology

We identified 125 suspect measles cases (52% females) in Longding district. The median age of suspected cases was 4 years (range: 1 month to 35 years), and 96% were <15 years of age. Aside from fever and rash, 99% (124/125) had cough, 97% (122/125) coryza, and 75% (94/125) conjunctivitis. The outbreak in Longding district began in April 2017, peaked in early June 2017, and concluded by the end of June 2017 [Figure 2]. The index case was a 7-year-old female Konsa village resident with no history of measles vaccination, who had rash onset on April 6, 2017, and a history of travel in late March 2017 to the neighboring district, Tirap, where a measles outbreak had occurred from December 2016 to April 2017. Five measles-related deaths occurred during the outbreak in Longding district for an overall 4% CFR. Among the cases reported in Longding district, Konsa village contributed 83% (104/125) of cases with village AR of 14% (104/764) and CFR of 5% (5/104). On 20 April 2017, Konsa village hosted a mass gathering local festival attended by local villagers and family relatives from neighboring villages. The index case and four of her contacts reported attending the festival which falls within the infectious period of the disease. Among the 104 Konsa village resident cases, 10 cases with rash onset dates in April reported attending the same local community festival as the index case in Konsa village.
Figure 2: Suspected measles cases by date of rash onset, Longding district, Arunachal Pradesh, India, March to June 2017 (n = 125).

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Retrospective cohort study of Konsa village

We surveyed all 109 houses of Konsa village, enrolling 87 children ≤5 years of age from 47 houses. There were 48 houses with no children ≤5 years, and 14 houses were locked at the time of the visit. There were no refusals. We identified 75 suspected cases (56% females) for a Konsa village-specific AR of 86% (75/87) among children ≤5 years. The median age was 36 months (range: 1–60 months). Complications were reported in 40% (30/75) of suspected cases. Among the 30 suspected cases with reported complications, 80% (24/30) had diarrhea, 20% (6/30) had respiratory complications, and 7% (2/30) had ear discharge. Only 7% (5/75) of suspected cases were reported to have been taken to the nearest health facility (military dispensary), but none were hospitalized because the nearest hospital was 25 km away from the village. Among the 75 suspected cases in Konsa village, 45% (34/75) had received Vitamin A through health outreach programs between June 9 and 14, 2017.

There were five deaths (3 females) for a Konsa village-specific CFR of 7% (5/75). Their median age was 18 months (range: 2–48 months); two were <9 months. None of the five suspected cases who died had received any type of vaccine, Vitamin A, or medical care, and all died within 2–8 days of rash onset. All five had respiratory complications and four had diarrhea.

Among the 65 children in the 12–60 months' age group, only 3 (5%) had vaccination cards. Based on these cards and maternal recall, coverage was calculated to be 9.2% (6/65) for MCV1, 3.1% (2/65) for MCV2, 4.6% (3/65) for the third dose of pentavalent vaccine (diphtheria, pertussis, tetanus, hepatitis B, and Haemophilus influenzae type B), and Vitamin A coverage was 4.6% (3/65) [Table 1]. Only one child, a newborn delivered in a hospital, (1/87) was vaccinated appropriately for her age by receiving BCG, zero dose polio vaccine, and hepatitis birth dose as per India's RI program. The most common reported reason for incomplete or no vaccination was a lack of awareness regarding vaccination days (52/86 [60.5%]). Vaccine effectiveness for MCV1 was calculated at 100% considering only MCV-eligible children for calculating the AR among unvaccinated children. No MCV1 (RR = 7.3, 95% CI = 1.3–53) and attending the local festival (RR = 5.3, 95% CI = 1.5–18.5) were associated with being a measles case.
Table 1: Vaccination and Vitamin A coverage and reasons for incomplete vaccination in a cohort of children<5 at Konsa village, Longding district, Arunachal Pradesh, India, March to June 2017

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Laboratory investigations

During the outbreak investigation, 76.5% (13/17) of the suspected cases tested positive for measles by serum IgM (8) or PCR of nasopharyngeal swabs (4) or both (1) [Table 2].
Table 2: Laboratory results of measles outbreak, Longding district, Arunachal Pradesh, India, March to June 2017 (n=17)

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Routine immunization system evaluation

Health facilities and human resources

Longding district has a public district hospital, 3 public community health centers, and 19 public health outposts. There were no private health facilities in the district. Konsa village is served by the Konnu Health Outpost, located 7 km from the village, but which was not functional at the time of investigation because it had no health workers staffing it for the last 6 months. The Konnu Health Outpost is supervised by the Pongchau Community Health Center (CHC), which looks after the planning and workforce deployment. Although Pongchau CHC has positions for 11 medical officers and 11 nurses, only one medical officer and two nurse positions were filled. There is a functional military dispensary at the outskirts of Konsa village that provides basic health services but not vaccinations.

Planning and monitoring

Pongchau CHC prepares the RI microplan for the subdistrict by compiling information from the health outposts through a household survey of all the villages. The available RI microplan had information on the number of children eligible for vaccination in Konsa village. However, it lacked information on vaccination plans, vaccine delivery, and monitoring. Immunization coverage charts to mark progress were not available at the CHC.

Supply chain/logistics

Pongchau CHC had vaccines delivered from the district each month. It had one ice-lined refrigerator and one deep freezer. However, irregular power supply was reported, and no power backup was observed. Of the temperature charts from June 2016 to June 2017, temperature recordings were missing from January to May 2017. With a target population of 1136 children <2 years old, approximately 190 MCV doses plus buffer stock would be required per month, but we only observed 10 five-dose vials in stock at the time of review in June 2017. Vitamin A and vaccination cards were not available at the CHC for the last 6 months.

Routine immunization sessions

Between January and June 2017, there were records of only two RI sessions conducted in Konsa village as part of the Mission Indradhanush campaign. There should have been at least four sessions in that period. In addition, there were no records available of RI sessions held in previous years.


   Discussion Top


We documented a laboratory-confirmed measles outbreak in Longding district, Arunachal Pradesh, on the Indo-Myanmar border. Realizing the importance of the health system as underlying causes of the outbreak, we included a robust immunization health system evaluation approach in addition to a standard outbreak investigation. The outbreak occurred in a setting of very low measles vaccination coverage and a weak RI delivery system resulting in the accumulation of a large cohort of susceptible populations in this remote village. Disease transmission during the outbreak was likely amplified by attending a mass gathering – a local festival in Konsa village. The investigation found a high AR among children <5 years and no cases in older age groups, indicating that almost all the children <5 years in Konsa village were susceptible to measles infection because of a nearly universal lack of routine vaccination.

Our investigation registered a high case fatality rate (7%) in this measles outbreak among children <5 years in Konsa village. The finding is higher than that in other parts of India where mortality ranges from 0.5% to 3% during measles outbreaks.[12],[13],[14] This was likely related to poor health-care access and low Vitamin A coverage. Of those who died, none were taken to a health facility despite having respiratory or diarrheal complications; none were vaccinated against measles; none had received Vitamin A during the course of illness. Our finding aligns with WHO reports of 3%–6% case fatality in populations with high levels of malnutrition, particularly Vitamin A deficiency, and a lack of adequate health care.[15]

One of the key strategies for measles elimination is to achieve and maintain at least 95% population immunity with two doses against measles.[4] A robust RI system at the district and state level is required to achieve the elimination target. However, for Konsa village, RI was a challenge due to the difficult hilly terrain, coupled with mobility restrictions due to lack of public transport and safety issues for health-care workers. There were additional challenges of limited infrastructure and inadequate workforce. The result was a lack of RI sessions being held in the village leading to very low vaccination coverage. To make inroads toward national coverage targets of RI (>90% full immunization), the Government of India launched the Mission Indradhanush campaign in 2014 to provide periodic intensification of RI, particularly within high-risk districts, including Longding district. The campaign was conducted from March to June 2017 in Longding district, with special emphasis on high-risk villages such as Konsa village. Although Mission Indradhanush has made inroads toward improving coverage, the outbreak in Longding district demonstrates the simultaneous need for sustainable strengthening of RI systems, particularly related to human resources, training, planning, supply, and mobilization.

Our outbreak investigation led state and district health authorities to carry out health outreach programs from June 7 to 13, 2017, in the affected villages for administration of Vitamin A and management of serious cases by a pediatrician who was assigned to the outbreak investigation. A measles catch-up campaign was carried out in September 2017 in the district, targeting children aged 9 months to <10 years. The district health authority posted a nurse at the health outpost catering to Konsa village from August 2017, leading to the re-initiation of RI activities in the village.

Our investigation was not without limitations. There was an inherent recall bias in using a questionnaire to collect vaccination history since most children did not have a vaccination card. Despite the bias possibly overestimating vaccination coverage rates, as responders might provide sought after responses, the interviewers still recorded extremely low rates of vaccination coverage.[16],[17] The exact clinical presentation dates also could have been misrecorded. However, the interviewers jogged caregiver memories by identifying important events that took place in the village.


   Conclusion Top


This investigation is an important characterization of a vaccination system in a region with limited documentation. To our knowledge, it is the first published report of a measles outbreak from Arunachal Pradesh that describes the ongoing transmission of measles in Longding district and surrounding areas. The findings of the investigation highlight the need to provide measles vaccine and Vitamin A in communities in hard-to-reach areas with low coverage to achieve regional and global goals. Our investigation highlighted the heterogeneity of vaccine coverage within smaller administrative sublevels that do not reflect the national and state immunization rates in India. In isolated pockets such as Konsa village, immunization is not meeting the set targets highlighting the need to think innovatively of ways to increase vaccination scope and coverage, for example, offering vaccination at local festivals and prioritizing staffing of hard-to-reach health centers. These and other interventions could help India to achieve the measles elimination target by 2020, in addition to moving toward universal health coverage.

Acknowledgments

We would like to thank Dr. Nishant Kumar, Dr. Partha Rakshit, Dr. C. S. Aggarwal and Sh. Pramod Kumar of National Centre for Disease Control, Delhi, for their contribution and support to the investigation. The team also wishes to acknowledge the support of the following persons: Sh. Himanshu Gupta (Deputy Commissioner, Longding district, Arunachal Pradesh), Arunachal Pradesh state, and Longding district health officials and staff: Dr. Emo Basar, Dr. Singpor Rigia, Dr. Langngam Wangsu, Dr. Bhuma Namshoom, Dr. Kapnai Wangsu, and Mr. Katwang Wangham (Chief of Konsa Village).

Financial support and sponsorship

This public health activity was conducted by the India EIS officers at the request of the Government of Arunachal Pradesh state. The National Centre for Disease Control receives funding support for the India EIS Program through cooperative agreement No. NU2GGH001904GH10-1001 from the U.S. Centers for Disease Control and Prevention, Center for Global Health, Division of Global Health Protection. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Conflicts of interest

There are no conflicts of interest.



 
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