1. David Featherstone EPI / IVB WHO/HQ Measles Partners Meeting 23-25 September 2008 Washington Global Measles Rubella Laboratory Network: Update

2. WHO Vaccine Preventable Disease Lab NetworkOverviewOverview Why do we need a laboratory network? How is it performing? Challenges and opportunities

3. WHO Vaccine Preventable Disease Lab Network Why do we need a laboratory network?

4. 4 4 Potential measles transmission pathways!

5. WHO Global Measles and Rubella Laboratory Network: 2001-2007 124 Sub-National Labs 10 Sub-National Labs 164 countries = Global Specialised Labs National Laboratories Regional Reference Labs 172 Global Specialised Labs National Laboratories Regional Reference Labs 80 N= 679 labs + 331 "SNLs" 31 "NLs" 2007 2001 As of July 2008 5

6. WHO Vaccine Preventable Disease Lab Network 6 Integrated lab activities (Excluding sub-national Labs)

7. WHO Vaccine Preventable Disease Lab Network 7 Data as of June 08 ~ 400,000 tests run in 2007 for M & R LabNet Workload: Measles serology samples tested (~80% samples also tested for Rubella in 2007)

8. WHO Vaccine Preventable Disease Lab Network 8 98% passed 94% passed 90% passed 94% passed 96% passed Score 98.5% 98.8% Year of PT Distribution WHO LabNet Quality - Proficiency Test Measles IgM Results 2001-2007

9. WHO Vaccine Preventable Disease Lab Network 9 Capacity building Training workshops –New labs recently incorporated into LabNet –New staff: constant staff turnover –New techniques –Reference/Specialised Lab staff visit labs –Lab staff visit Reference/Specialist Labs, Skills –Serology, QA/QC, –Lab Management, Data Management, –Virus isolation, –Molecular Techniques, Sequencing, –Trouble shooting AFREMREURSEARPAHO Serology3 1 12 Cell culture1 1 PCR Sequencing QA/QC31 Lab Workshops 2007-08

10. 10 Challenge - 1 Scaling-up molecular surveillance to identify transmission pathways

11. 11 WHO Vaccine Preventable Disease Lab Network Development of WHO Global genotype database Password protected SharePoint on-line access Viruses submitted from 1979 to 2008 Real-time access Number of viruses GenotypesCountriesWHO RegionsMeasles282318746 Rubella19411215 Data as of 10 Sept 2008 11

12. WHO Vaccine Preventable Disease Lab Network Measles Genotype Detection- WHO LabNet 1979 -2008 No. of viruses submitted 12

13. Global Measles Virus Genotypes 2007 Key D4 B3 D6 D9 D8 D5 H1

14. Global Measles Virus Genotypes 2008 (Sept) Key D4 D8 D9 H1 D5

15. During January 1–July 31, 2008, 131 measles cases were reported to CDC from 15 states and the District of Columbia (DC)…. Among the 131 cases, 17 (13%) were importations: three each from Italy and Switzerland; two each from Belgium, India, and Israel; and one each from China, Germany, Pakistan, the Philippines, and Russia….. Nine of the importations were in U.S. residents who had traveled abroad, and eight were in foreign visitors. An additional 99 (76%) of the 131 cases were linked epidemiologically to importations or had virologic evidence of importation….

16. 16 Challenge - 2 Developing and validating procedures for non-invasive collection of samples and transportation without cold chain

17. 17 Alternative samples to serum for measles and rubella diagnosis WER: 25, 2008, 83, 225–232 andMMWR: 2008; 57:657-660

18. WHO Vaccine Preventable Disease Lab Network 18 Schematic of wild type measles virus infection* Incubation 7-18 days Patients positive Day of illness** 3 IgM: Serum/DBS/OF 7 14 28 35 90 21 60 Virus culture -31 5 25% 50% 100% 75% Fever Rash **Day 0 = first day of rash (-3 to 5 days) (0 to 5 days) Virus detection: OF Virus detection: DBS DBS=Dried Blood Spot OF = Oral fluid sample Virus detection = RT-PCR * WER: 25, 2008, 83, 225–232 andMMWR: 2008; 57:657-660 June 2008

19. 19 Challenge - 3 Meeting the programmatic need for increased workload and reduced testing turnaround time

20. 20 Surveillance Indicators through the Elimination Stages: PAHO 2005 1997 2000

21. Source:MESS EPI week 52 Samples Processed Laboratory Workload in Americas: Specimens Processed and Reporting Timeliness

22. WHO Vaccine Preventable Disease Lab Network No of Labs (AFRO) Approx cost of supplies / year Approx cost per lab Polio16$800,000$50,000 Measles Rubella* 38$548,000$14,500 YF23$40,000$2,000 Equipment (12%) Assays (78%) Computers/IT (1%) Consumables other than assays (8%) * Measles & Rubella costs 2006 Recurring costs in maintaining LabNet WHO African Region

23. WHO Vaccine Preventable Disease Lab Network Global number of kits WHO procured per annum

24. WHO Vaccine Preventable Disease Lab Network Total Cost of kits WHO procured per annum

25. WHO Vaccine Preventable Disease Lab Network Polio Polio –CDC, USAID –DIFID –Rotary –UNF –Gov'ts of Netherlands, Finland, Italy –Others Measles and rubella Measles and rubella –CDC YF YF –IFFIM –CDC (reagents) JE JE –PATH / CVP –CDC (GDD) WHO Major external partners of VPD LabNet National Ministries of Health provide infrastructure and staffing costs

26. Funds Needs

27. WHO Vaccine Preventable Disease Lab Network Validating procedures for transporting samples without refrigeration Reducing meetings frequency: ~every 2 nd year Integrating training and meetings with other disease programmes Encouraging countries to take on more costs in their surveillance programme budget Local production and validation of measles and rubella assays: China, Russian Federation Meeting the Challenge of Limited funding

28. WHO Vaccine Preventable Disease Lab Network Serving 164 countries Timely reliable results Virus tracking and information sharing Outbreak detection and control Challenge -Balancing needs with resources Meeting challenge - Innovation and "belt-tightening" THANK YOU!! Conclusions – "The Best Kept Secret" Global public good