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Measles outbreak risk in Pakistan: exploring the potential of combining vaccination coverage and incidence data with novel data-streams to strengthen control.

ABSTRACT: Although measles incidence has reached historic lows in many parts of the world, the disease still causes substantial morbidity globally. Even where control programs have succeeded in driving measles locally extinct, unless vaccination coverage is maintained at extremely high levels, susceptible numbers may increase sufficiently to spark large outbreaks. Human mobility will drive potentially infectious contacts and interact with the landscape of susceptibility to determine the pattern of measles outbreaks. These interactions have proved difficult to characterise empirically. We explore the degree to which new sources of data combined with existing public health data can be used to evaluate the landscape of immunity and the role of spatial movement for measles introductions by retrospectively evaluating our ability to predict measles outbreaks in vaccinated populations. Using inferred spatial patterns of accumulation of susceptible individuals and travel data, we predicted the timing of epidemics in each district of Pakistan during a large measles outbreak in 2012-2013 with over 30 000 reported cases. We combined these data with mobility data extracted from over 40 million mobile phone subscribers during the same time frame in the country to quantify the role of connectivity in the spread of measles. We investigate how different approaches could contribute to targeting vaccination efforts to reach districts before outbreaks started. While some prediction was possible, accuracy was low and we discuss key uncertainties linked to existing data streams that impede such inference and detail what data might be necessary to robustly infer timing of epidemics.

SUBMITTER: Wesolowski A

PROVIDER: S-EPMC6090714 | biostudies-literature | 2018 Sep

REPOSITORIES: biostudies-literature

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Measles outbreak risk in Pakistan: exploring the potential of combining vaccination coverage and incidence data with novel data-streams to strengthen control.

Wesolowski Amy A Winter Amy A Tatem Andrew J AJ Qureshi Taimur T Engø-Monsen Kenth K Buckee Caroline O CO Cummings Derek A T DAT Metcalf C Jessica E CJE

Epidemiology and infection 20180604 12

Although measles incidence has reached historic lows in many parts of the world, the disease still causes substantial morbidity globally. Even where control programs have succeeded in driving measles locally extinct, unless vaccination coverage is maintained at extremely high levels, susceptible numbers may increase sufficiently to spark large outbreaks. Human mobility will drive potentially infectious contacts and interact with the landscape of susceptibility to determine the pattern of measles ...[more]

PMID: 29860954

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Project description:INTRODUCTION:Measles elimination depends on the successful deployment of measles containing vaccine. Vaccination programs often depend on a combination of routine and non-routine services, including supplementary immunization activities (SIAs) and vaccination weeks (VWs), that both aim to vaccinate all eligible children regardless of vaccination history or natural infection. Madagascar has used a combination of these activities to improve measles coverage. However, ongoing massive measles outbreak suggests that the country was in a "honeymoon" period and that coverage achieved needs to be re-evaluated. Although healthcare access is expected to vary seasonally in low resources settings, little evidence exists to quantify temporal fluctuations in routine vaccination, and interactions with other immunization activities. METHODS:We used three data sources: national administrative data on measles vaccine delivery from 2013 to 2016, digitized vaccination cards from 49 health centers in 6 health districts, and a survey of health workers. Data were analyzed using linear regressions, analysis of variance, and t-tests. FINDINGS:From 2013 to 2016, the footprint of SIAs and VWs is apparent, with more doses distributed during the relevant timeframes. Routine vaccination decreases in subsequent months, suggesting that additional activities may be interfering with routine services. The majority of missed vaccination opportunities occur during the rainy season. Health facility organization and shortage of vaccine contributed to vaccination gaps. Children born in June were the least likely to be vaccinated on time. DISCUSSION:Evidence that routine vaccination coverage varies over the year and is diminished by other activities suggests that maintaining routine vaccination during SIAs and VWs is a key direction for strengthening immunization programs, ensuring population immunity and avoiding future outbreaks. FUNDING:Wellcome Trust Fund, Burroughs Wellcome Fund, Gates Foundation, National Institutes of Health.

Project description:BackgroundA measles outbreak occurred in a western county of China in 2013, the year after China's historic nadir of measles. We conducted a field investigation to identify gaps in measles vaccination coverage and immunization program weaknesses, and to provide recommendations for measles outbreak response and immunization program improvement.MethodsWe analyzed surveillance data from 2008 to 2013 to describe the measles epidemiology of the county. Measles-containing vaccine coverage was estimated using two methods: previously-reported administrative coverage and an estimation of coverage by clinic-kept vaccination records (n = 542). We conducted a rapid field coverage assessment in a migrant population village to evaluate coverage after emergency vaccination. We conducted a review of hospital records of measles cases to address the role hospital transmission played during the early stage of this outbreak.ResultsThere were 153 cases in the outbreak, primarily among children too young to vaccinate, unvaccinated children less than 3 years old, and adults. Measles-containing vaccine coverage by the field assessment showed that 20% of children aged 8-17 months had zero doses, and 9% of ?2 years old children had fewer than two doses. The vaccination statuses of all adult cases were either zero doses or unknown. At least 61% of cases had been hospitalized. The proportion of cases who had been hospital-exposed 7 to 21 days prior to rash onset decreased from 52% to 22% after hospitals strengthen their isolation measures.ConclusionsThis outbreak was a result of measles vaccination coverage gaps among young children and adults, and insufficient hospital isolation of cases. The lower coverage seen in the field estimation compared with reported coverage showed that reported coverage could have been overestimated. Hospitals were sites of transmission in the early stage of the outbreak. A strict hospital isolation policy could decrease spread of measles. Emergency vaccination was associated with stopping measles transmission in low coverage areas.

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Dataset Information

Measles outbreak risk in Pakistan: exploring the potential of combining vaccination coverage and incidence data with novel data-streams to strengthen control.

Publications

Measles outbreak risk in Pakistan: exploring the potential of combining vaccination coverage and incidence data with novel data-streams to strengthen control.

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