1. Epidemiology of Vaccine Preventable diseases in Iran
Dr Seyed Mohsen Zahraei
Center for Communicable Disease Control

2. Outline The mean and importance of surveillance
Surveillance system functionality
Regional targets for Vaccine Preventable Diseases
Progress towards achieving the targets in Polio, Measles and Rubella
Challenges and opportunities

3. Definition of Surveillance
Disease surveillance is the ongoing systematic collection, analysis and interpretation of data and dissemination of INFORMATION to those who need to know FOR ACTION to be taken

4. Collection Analysis and Interpretation Surveillance Action
Dissemination

5. Importance of VPDs surveillance:
Demonstrate the real effectiveness of the vaccination programme in reaching its objective, reduction of VPDs: Measles control/elimination, MNTE, control of diphtheria and pertussis,…..
Demonstrate the need for intervention: introduction of new vaccines
Dangerous if not properly implemented: drawing incorrect conclusion:
decreasing trend/low estimate of a disease, the programme is doing fine
low burden of a disease, the new vaccine is not a priority

6. Process & Stages of Surveillance
Notification of suspect case
Case investigation & specimen collection
Reporting
Laboratory testing
Integration of field and laboratory data
Final case classification
Feedback

7. Core Surveillance Indicators
Timeliness of reporting
Reporting rate
Representativeness of reporting
Adequacy of epidemiological investigation
Timeliness of notification
Laboratory confirmation
Agent detection
Specimen transport & lab reporting

8. Measles Surveillance in the Elimination Phase
Surveillance priorities:
Confirm all cases
Detect virus from all outbreaks (chains of transmission)
Surveillance system attributes:
Sensitive – identify all suspect cases of measles & rubella
Timely – prompt notification, investigation and response
Complete -- case investigations, laboratory confirmation & virus detection

9. Surveillance Indicators (1)
Timeliness (& completeness) of reporting
Proportion of surveillance units reporting to the national level on time (Target: >80%)
Used to identify poorly functioning units / districts / governorates / countries

10. Surveillance Indicators (2)
Reporting rate
Reporting rate of discarded non-measles non-rubella cases at the national level
Target: >2 cases per 100,000 population per year
Representativeness of reporting
Proportion of sub-national (province or governorate) units reporting >2 discarded cases/100,000 pop/yr
Combine units, if needed, to achieve >100,000 pop
Target: >80%
Used to assess surveillance sensitivity at national & sub-national levels

11. Surveillance Indicators (3)
Adequacy of investigation
Proportion of all suspected measles & rubella cases with adequate investigation initiated within 48 hours after notification
An adequate investigation includes collection of all relevant data elements from each suspected case
Data elements: Identifiers, residence, place of infection, age, sex rash onset date, specimen collection date, etc.
Target: >80%
Used to assess timeliness & completeness of case investigation (epidemiological component)

12. Surveillance Indicators (4)
Laboratory confirmation
Proportion of suspected cases with adequate specimen for detecting acute measles or rubella infection collected and tested by a proficient laboratory.
Adequate specimens include serum sample, DBS, or oral fluid, taken within 28 days after rash onset
Cases not tested but confirmed by epi-linkage to a confirmed case of measles, rubella or other communicable disease excluded from denominator
Target: >80%
Used to assess completeness of case investigation (“serological” component)

13. Surveillance Indicators (5)
Virus detection
Proportion of laboratory-confirmed outbreaks (chains of transmission) with adequate specimens for detecting measles or rubella virus collected and tested in an accredited laboratory.
Adequate specimens include a) throat swabs or urine samples for virus isolation (collected <5 days after rash onset), or b) throat swabs or oral fluid samples for molecular detection (collected <14 days or <21 days, respectively, after rash onset)
Target: >80%
Used to assess completeness of case investigation (virological component)

14. Surveillance Indicators (6)
Timeliness of specimen transport
Proportion of specimens received at the laboratory <5 days [Target: >80%]
Timeliness of laboratory reporting
Proportion of results reported by the laboratory <4 days of specimen receipt [Target: >80%]
Used to assess timeliness of case investigation (epidemiological & laboratory components)

15. Summary
Standardized definitions have been developed for case classification & elimination verification
In the elimination phase, surveillance for measles & rubella needs to be
Geographically representative
Sensitive
Timely
Complete
Current indicators are used to assess quality of case investigations & overall surveillance system
Targets for indicators (>80%) are minimums

16. The Targets: for each country
Soonest possible (for countries that haven’t achieved yet)
Achieve at least 90% DPT3 coverage at national level AND 80% in every district (target date 2010)
Eliminate MNT soonest possible (target date 2007)
By 2012
Eradicate polio
By 2015,
Eliminate measles (regional target)
Reduce HBsAg prevalence to < 1% among <5 years children (Regional target)
Reduce VPDs morbidity and mortality by 2/3 compared to 2000 (GIVS goal)
Introduce new vaccines (Hib, PCV and Rota) to all countries as soon as possible (RC58, 2011)

17. Poliomyelitis Eradication Initiative The End Game

18. Poliomyelitis was selected for eradication because :
There is no animal reservoir.
There is no chronic carrier state.
Poliovirus survives poorly in the environment.
Presence of effective vaccine against the disease

19. The Global Polio Eradication Emergency Action Plan aims to boost vaccination coverage in Nigeria, Pakistan and Afghanistan, the three remaining polio endemic countries, to levels needed to stop polio transmission.

20. Polio-free Status of 21 Countries of EMRO is Maintained
- cVDPV in Yemen 2011 last case Oct 2011
- Continuous cVDPV in Somalia from with last case in 23/07/2012
Polio Cases
2011
September 2012
Country P1 P3
P1P3
Pakistan
196 2 32 1
Afghanistan 80 17
EMRO 09/09/2012

21. % of NP AFP cases 6-< 59 months with 3 or more OPV doses
by province in EMR countries, 2012
Routine OPV3 coverage, 2011
Source: WHO/UNICEF Estimates of National Immunization Coverage
EMRO 09/09/2012

22. Immunity profile of NP AFP cases 6-59 months in
EMR countries, 2012 up to 09/09/12

23. VDPVs isolated in EMR 2005 2006 2007 2008 2009 2010 2011 2012 AFG EGY
Country
2005
2006
2007
2008
2009
2010
2011
2012
AFG
cVDPV2 (01)
cVDPV2 (05)
cVDPV 2 (01)
EGY
aVDPV2 (Sewage Behira)
iVDPV3 (01)
aVDPV 2 (Sewage Behira)
aVDPV 1 Helwan-Cairo
iVDPV1 (01)
iVDPV2 (01)
IRAN
iVDPV1 + iVDPV2 (01)
iVDPV2 (02)
KWT
IRAQ
MOR
iVDPV2
Detected in Spain
SAA
SOM
VDPV2 (02)
cVDPV2 (03)
cVDPV2 (07)
cVDPV 2 (02)
cVDPV2 (09)
SYR
VDPV2 (01)
aVDPV 2(01)
Sudan
aVDPV2 (01)
South Sudan
TUN
iVDPV2 (1)
iVDPV1 (a)
P1 iVDPV (a)
P3 iVDPV? (b)
YEM
cVDPV 2 (09)
aVDPV3 (01) 23

28. Measles and Rubella Elimination in EMR Countries

29. Measles cases down by 62% Measles deaths down by 74%
Reported cases of measles
Measles cases down by 62%
Measles deaths
down by 74%
measles cases show a declining trend over the past 10 years, as countries in all regions accelerated activities to control measles. But resurgence of outbreaks particularly in Africa (blue part of bars and europe (red part of bars) account for increasing number seen from 2010.
But overall trends for mortality are on the low side… amazing progress overall
Progress in global measles control, 2000–2010. WER 3 Feb 2012, vol. 87, 5 (pp 45–52)
Lancet in press; 2012 IVB model by Simons, Ferrari et al.

30. Source: Country reports Inadequate surveillance
2,052
Source: Country reports
Inadequate surveillance

32. Measles Cases, Incidence and Virus Genotypes, 2009- 2012*
Year
Measles Suspected Cases
Confirmed Measles cases
Measles Incidence/Million
Detected Genotype
Lab
Epi-Linked
Clinical/ Compatible
Total
2009
1282
118 7
132
257
3.4
D4 , H1
2010
2489
259
275
534
7.15
D4 , D1
2011
2641 18
114
135
1.8 D4
2012
2394
154 4 49
201
2.6
B3, H1, D4
* Up to August

33. Measles Confirmed Cases, 2009 – 2012*
* Display in line graph the distribution of confirmed measles cases by month for 2009 – 2012 up to August

34. Geographical Distribution Of Confirmed Measles Cases By Province, 2009 - 2012
Map 2009
Map 2010
Map 2012
Map 2011

35. Confirmed measles Cases ( Lab+Epi-linked ) by age group 2009 - 2012

36. Source: Country reports
Inadequate/No surveillance

37. Rubella detected cases based on fever and rash surveillance system, Iran, 2005-2011
Suspected cases
Number of Tested
Rubella Positive
Measles positive
2005
 536
410 11 6
2006
 943
771 15 45
2007
 900
796 5 21
2008
 972
868 10
2009
 1282
1159 9
118
2010
 2489
2212 22
258
2011
 2476
2232 18
Total
9598
8448 87
460

38. CRS Surveillance in Iran
Established in 2004, after MR mass campaign.
Accelerated passive surveillance, comprehensive
All hospitals which
may admit suspected cases
are covered

39. CRS suspected Case Definition
An infant (0-11 months) whose mother had suspected or confirmed history of rubella in pregnancy
An infant (0-11 months) with heart disease and or ophthalmic disease and or deafness

42. CRS suspected cases by sign

43. Summary Progress Challenges Well developed PHC network
High immunity level
Robust surveillance system
Challenges
New reporting sites
Training
Private sector partnership
Need to performance indicators