Measles outbreak investigation in Ginnir district of Bale zone, Oromia region, Southeast Ethiopia, May 2019

Epidemiology of measles outbreaks, incidence and associated risk factors in Ethiopia from 2000 to 2023: a systematic review and meta-analysis

BACKGROUND

Although a universal vaccine is available and Ethiopia is working outstandingly towards measles elimination, a recurrent measles outbreak has occurred each year in different parts of the country. Therefore, understanding the epidemiology of measles cases, the incidence of confirmed measles virus cases and related risk factors is crucial. Here, we conducted a systematic review and meta-analysis to summarize information regarding the epidemiology, measles incidence rate and risk factors for national measles infections occurring in the past two decades, from 2000 to 2023.

METHODS

Data from electronic databases, including PubMed, African Journal Online, WHO databases and Google Scholars, were searched to identify studies describing measles outbreaks, incidence rates and associated factors in Ethiopia that occurred between 2000 and 2023. Important basic information was extracted in an Excel spreadsheet and imported into Comprehensive Meta-analysis Software version 3 to evaluate the associations between measles outbreaks and different risk factors. We pooled the odds ratios (ORs) and 95% confidence intervals (CIs) for every included risk factor to evaluate the associations with measles outbreaks.

RESULTS

We included 36 studies involving 132,502 patients with confirmed measles cases in Ethiopia. The results of this systematic review and meta-analysis revealed that measles outbreaks were more frequently reported in the Oromia region (73,310 (33.1%)), followed by the Southern Nation Nationalities of Ethiopia region (29,057 (13.4%)). The overall pooled analysis indicated that the prevalence of measles susceptibility was 67.5% (95% CI: 67.3-67.8%), with an I2 of 99.86% and a p value for heterogeneity < 0.0001. The non-vaccinated status of the children, their contact history with measles cases, their travel history, the presence of cases in family or neighbors, and malnourished patients were identified as factors associated with the high prevalence and recurrent measles infections in Ethiopia.

CONCLUSION

The results of this systematic review and meta-analysis indicated that the pooled prevalence of measles infection was high, which is a public health concern in Ethiopia. Thus, strengthening healthcare services, regular vaccination campaigns, and the integration of health education activities with other services may decrease the incidence rate.

Measles outbreak investigation in Berhet District, North Shewa, Ethiopia

Introduction

Measles, though usually self-limiting, can have severe consequences influenced by factors such as vaccination and nutrition, notably vitamin A deficiency and malnutrition. Despite progress, contextual changes and implementation issues have hampered efforts, resulting in increased outbreaks and cases of measles. This study seeks to pinpoint outbreak features, risk factors, and strategies for preventing and controlling measles.

Methods

A descriptive cross-sectional study and a 1:2 unmatched case-control study design were employed. All 101 suspected measles cases listed on the line-list were included in the descriptive research, with 60 measles patients and 120 controls included in the case-control investigation. Line-list data were cleaned and analyzed using a pivot table in Microsoft Excel 2016. Subsequently, the data were cleaned, entered into Epi Info 7.2, and exported to SPSS 26 for analysis.

Results

Twenty cases occurred per 10,000 individuals. Men accounted for 67.3% of cases, with ages ranging from 5 months to 45 years and mean and standard deviations of 9.6 and 7.6, respectively. Age group of 5-14 years comprised 57.4% of cases, followed by 1-4 years with 24.8%. Being unvaccinated against measles showed an adjusted odds ratio (AOR) of 12.06 (95% CI: 3.12-46.52). Travel history to regions with active cases had an AOR of 5.73 (95% CI: 1.78-18.38). Contact with a measles patient showed an AOR of 10.3 (95% CI: 3.48-30.5). Understanding the measles transmission mechanism had an AOR of 0.164 (95% CI: 0.049-0.55), and awareness of the disease's preventability had an AOR of 0.233 (95% CI: 0.67-0.811). All factors were independently associated with the illness.

Conclusion

This outbreak affected a broader age range with a high attack rate, mainly in the age group of 5-14-years. Over 35% of cases lacked measles vaccination, indicating low administrative vaccine coverage. Factors contributing to the outbreak include lack of measles vaccination, travel to areas with active disease, contact with cases, and insufficient knowledge of measles transmission and prevention strategies among mothers and caregivers.

Second dose of measles-containing vaccine coverage and associated factors among children aged 24-36 months in Gondar city, Central Gondar, Northwest Ethiopia, 2023

Background

Measles caused 207,000 deaths worldwide in 2019. Ethiopia ranks among the top 10 countries in the world with the highest number of measles cases. However, the coverage of the second dose of measles-containing vaccine (MCV2) remains low. To increase coverage, the government of Ethiopia launched a nationwide measles vaccination campaign. Despite this intervention, the coverage is still below target, and there is scarce information in the study area. Therefore, this study aimed to assess MCV2 coverage and associated factors among children aged 24-36 months in Gondar city, Central Gondar, Northwest Ethiopia, 2023.

Methods

A community-based cross-sectional study was conducted among 621 children aged 24-36 months using a systematic random sampling technique from 25 April to 25 May. A pre-tested, interviewer-administered, and structured questionnaire was used and collected using Kobo Toolbox and then transferred to Stata version 17 for further analysis. The binary logistic regression model was used to identify factors, and the presence of an association was declared using a p-value of <0.05. Similarly, an adjusted odds ratio with a 95% confidence interval was used to interpret the direction and strength of an association.

Results

A total of 621 children, with a response rate of 98.1%, participated in the study. The coverage of the second dose of MCV was 75.68% (95% CI: 72.1-78.9). The following factors were significantly associated with measles-containing vaccine second dose (MCV2) coverage: father as the household head (AOR: 3.06, 95% CI: 1.43-6.44), first birth order (AOR: 4.45, 95% CI: 1.21-16.3), four and above antenatal care (ANC) follow-ups (AOR: 5.18, 95% CI:1.62-16.5), postnatal care (PNC) service utilization (AOR: 2.57, 95% CI:1.27-5.15), at least two doses of vitamin A uptake (AOR: 6.39, 95% CI: 2.67-15.2), mothers having high awareness (AOR: 1.97, 95% CI:1.15-3.4), and good perception (AOR: 3.6, 95% CI: 2-6.47) about measles vaccination.

Conclusion and recommendations

The coverage of MCV2 in the study area is lower than the national and global target of above 95%. Head of household, birth order, ANC follow-up, PNC service utilization, vitamin A uptake, awareness, and perception of mothers about measles vaccination were significant factors for MCV2 coverage. Creating awareness, increasing the perception of mothers about measles vaccination, and strengthening the ANC and PNC services will increase the coverage.

Measles outbreak investigation in Tocha district, southwestern Ethiopia: an unmatched case-control study

Background

Measles continues to be a public health challenge in Ethiopia. Rumors of suspected measles were notified on April 8, 2023 from Tocha district. We conducted an assessment to describe measles outbreak and determine risk factors for measles infection in the Tocha district of the Dawuro zone, Southwest Ethiopia.

Methods

We conducted a 1:2 unmatched case-control studies from April to May 2023. We took all 147 cases registered on line list for descriptive analyses. We used a total of 74 randomly selected cases and 147 controls for case-control part. Any person in Tocha district with laboratory-confirmed measles IgM antibody; or any suspected person epidemiologically linked to confirmed measles cases from March 23 to April 26 2023, were included in the case. Neighborhood who did not fulfill this standard case definition were included in controls. Data were collected using standardized questionnaires deployed on Kobo Collect. Descriptive analyses were conducted using Epi info version 7.2.5.0. The analyses were performed using Statistical Package for Social Science (SPSS) version 26. Binary logistic regression analyses were utilized to select candidate variables. We conducted multiple logistic regression analysis to identify determinants of measles infection at a p value ≤0.05 with 95% confidence interval.

Results

The overall attack rate of 22.64/10,000 for general population and 104.59/10,000 among under-five children were attributed to the outbreak with a case fatality rate of 2.72%. Vaccine coverage in the last year and this year were 73.52 and 53.88%, respectively, while vaccine effectiveness in the district was 79%. Poor house ventilation (AOR = 3.540, 95% CI: 1.663-7.535) and having contact history with the case (AOR = 2.528, 95% CI: 1.180-4.557) were positively related to measles infection while being previously vaccinated for measles (AOR = 0.209, 95% CI: 0.180-4.577) reduce risk of measles infections.

Conclusion

The highest attack rate was observed among children under 5 years of age, with a case fatality rate of 2.72%. Vaccination coverage was less than what expected to develop herd immunity. Strategies to increase vaccination coverage and strengthening surveillance systems for rumor identification and early responses to prevent person to person transmission are recommended.

Descriptive Analysis of Measles Outbreak in Liberia, 2022

Background

Liberia reported a large outbreak of measles involving all the counties in 2022. We conducted a descriptive analysis of the measles surveillance data to understand the trend of the outbreak and guide further policy action to prevent future outbreaks.

Methods

We analyzed the measles surveillance data from Epi week 1 to 51, 2022. All the laboratory-confirmed cases, clinically compatible and epidemiologically linked cases were included in the analysis, the variables of interest included the patient's age, sex, place of residence, measles classification, measles vaccination status, and outcome. We cleaned and analyzed the data using R version 4.2.0 and Arc GIS Pro. The demographic characteristics of the cases were presented, the progression of the cases was presented in Epicurve and the spatial distribution and the case fatality rate (CFR) of the case were presented at the district level using the Arc GIS Pro.

Results

The median age of the cases was 4 years (interquartile range: 2-8 years). Children under five years of age constituted 60% of the cases (4836/8127), and females accounted for 52% (4204/8127) of the cases. Only 1% (84/8127) of the cases had documentary evidence of receiving at least one dose of measles-containing vaccine (MCV). Only 3 out of 92 health districts in the country did not report a case of measles during the period under review. The overall cases fatality rate was 1% however CFR of up to 10% were reported in some districts.

Conclusion

The outbreak of measles involved almost all the districts of the country, exposing a possible nationwide suboptimal immunization coverage for MCV. The high CFR reported in some districts needs further investigation.

Attack rate, case fatality rate and determinants of measles infection during a measles outbreak in Ethiopia: systematic review and meta-analysis

BACKGROUND

Although Ethiopia is working towards measles elimination, a recurrent measles outbreak has occurred. To take appropriate measures, previously, many fragmented and inconsistent outbreak investigations were done, but there is no consolidated evidence on attack rate, case fatality rate, and determinants of measles infection during the measles outbreak. This systematic review and meta-analysis aimed to identify cumulative evidence on attack rate, case fatality rate, and determinants of measles infection during the outbreak.

METHODS

A systematic literature review and Meta-analysis was used. We searched Google Scholar, Medline/PubMed, Cochrane/Wiley Library, EMBASE, Science Direct, and African Journals Online databases using different terms. Investigations that applied any study design, data collection- and analysis methods related to the measles outbreak investigation were included. Data were extracted in an Excel spreadsheet and imported into STATA version 17 software for meta-analysis. The I2 statistics were used to test heterogeneity, and 'Begg's and 'Egger's tests were used to assess publication bias. The odds ratio (OR) with a 95% confidence interval (CI) was presented using forest plots.

RESULTS

Eight measles outbreak investigations with 3004 measles cases and 33 deaths were included in this study. The pooled attack rate (A.R.) and case fatality rate were 34.51/10,000 [95% CI; 21.33-47.70/10,000] population and 2.21% [95% CI; 0.07-2.08%], respectively. Subgroup analysis revealed the highest attack rate of outbreaks in the Oromia region (63.05 per 10,000 population) and the lowest in the Amhara region (17.77 per 10,000 population). Associated factors with the measles outbreak were being unvaccinated (OR = 5.96; 95% CI: 3.28-10.82) and contact history (OR = 3.90; 95% CI: 2.47-6.15).

CONCLUSION

Our analysis revealed compelling evidence within the outbreak descriptions, highlighting elevated attack and case fatality rates. Measles infection was notably linked to being unvaccinated and having a contact history. Strengthening routine vaccination practices and enhancing contact tracing measures are vital strategies moving forward.

Use of catch-up vaccinations in the second year of life (2YL) platform to close immunity gaps: A secondary DHS analysis in Pakistan, Philippines, and South Africa

BACKGROUND

Immunity gaps caused by COVID-19-related disruptions highlight the importance of catch-up vaccination. Number of countries offering vaccines in second year of life (2YL) has increased, but use of 2YL for catch-up vaccination has been variable. We assessed pre-pandemic use of 2YL for catch-up vaccination in three countries (Pakistan, the Philippines, and South Africa), based on existence of a 2YL platform (demonstrated by offering second dose of measles-containing vaccine (MCV2) in 2YL), proportion of card availability, and geographical variety.

METHODS

We conducted a secondary data analysis of immunization data from Demographic and Health Surveys (DHS) in Pakistan (2017-2018), the Philippines (2017), and South Africa (2016). We conducted time-to-event analyses for pentavalent vaccine (diphtheria-tetanus-pertussis-Hepatitis B-Haemophilus influenzae type b [Hib]) and MCV and calculated use of 2YL and MCV visits for catch-up vaccination.

RESULTS

Among 24-35-month-olds with documented dates, coverage of third dose of pentavalent vaccine increased in 2YL by 2%, 3%, and 1% in Pakistan, Philippines, and South Africa, respectively. MCV1 coverage increased in 2YL by 5% in Pakistan, 10% in the Philippines, and 3% in South Africa. In Pakistan, among 124 children eligible for catch-up vaccination of pentavalent vaccine at time of a documented MCV visit, 45% received a catch-up dose. In the Philippines, among 381 eligible children, 38% received a pentavalent dose during an MCV visit. In South Africa, 50 children were eligible for a pentavalent vaccine dose before their MCV1 visit, but only 20% received it; none with MCV2.

CONCLUSION

Small to modest vaccine coverage improvements occurred in all three countries through catch-up vaccination in 2YL but many missed opportunities for vaccination continue to occur. Using the 2YL platform can increase coverage and close immunity gaps, but immunization programmes need to change policies, practices, and monitor catch-up vaccination to maximize the potential.

Measles Outbreak Investigation in Garda Marta District, Southwestern Ethiopia, 2022: Community-Based Case-Control Study

Background

A measles outbreak can occur in the presence of an increased number of unvaccinated children; however, the vaccine was available many decades ago, and it is the foremost cause of child mortality, claiming 568 lives (mostly children) worldwide each day. The investigation was aimed at assessing the magnitude and identifying contributing factors for the measles outbreak in the Garda Marta District of Gamo Zone, Southwestern Ethiopia.

Methods

From January 20 to February 10, 2022, a descriptive and unmatched case-control study was used to describe the measles outbreak and identify the associated risk factors for measles infection. The descriptive analysis employed all 140 cases from the line list, while the case-control study used 51 cases and 102 controls to investigate factors associated with measles infection. Epi-data version 4.6.0.6 was used to code and enter data, which was then exported to SPSS version 27 for analysis. A standardized questionnaire was used to collect data. To declare statistical significance for the association, multivariable logistic regression with an adjusted odds ratio (AOR) and 95% CI was used.

Results

From a total of 140 measles cases reported from October 12, 2021, to March 09, 2022, 75 (54%) were females. Marta Laddo kebele was most affected (104 cases). Being unvaccinated (AOR: 2.84, 95% CI: 1.10-7.32), having a travel history (AOR: 4.24, 95% CI: 1.61-11.15), having a contact history (AOR: 6.34, 95% CI: 2.35-17.40), being unaware of the mode of transmission (AOR: 2.68, 95% CI: 1.16-6.37), and having moderate acute malnutrition (AOR: 4.44, 95% CI: 1.74-11.31) were factors significantly associated with the measles outbreak.

Conclusion

Being unvaccinated, travel history to measles outbreak area, contact history, knowledge of caretakers/mothers on the mode of transmission, and acute malnutrition were associated with the measles outbreak in the district. Therefore, strengthening routine measles immunization, mounting vaccination awareness and nutritional screening are recommended.

Measles outbreak investigation in Kasoshekumer kebele, Sinana district, South-Eastern Oromia, Ethiopia: A case-control study

Objective

This study aimed at verifying the outbreak, preventing further transmission, and identifying the risk factors for the outbreak.

Method

A case-control study design was conducted from March 4, 2020 to April 30, 2020, in Kasoshekumer kebele of Sinana district. Thirty-seven carer-patient pairs and 74 controls were recruited in a 1:2 case-control ratio. Patients were selected using a national standard case definition of the Ministry of Health. Controls were selected from neighbors of patients and interviewed after the second incubation period from the last patient of the outbreak by a structured questionnaire similar to patients. All cases were included while controls were selected purposively for their exposure status. Vaccine efficacy, attack rate, and case fatality rate were conducted as a descriptive epidemiology. Multivariate analysis was used to identify associated factors.

Result

Out of 109 study participants, there were 37 cases and 72 controls. The mean age was 58.8 months with ±54 standard deviation. Thirty-one (83.8%) of the cases had a known contact history and 23 (62.2%) were unvaccinated. The age-specific attack rate was 36/1000 in <5 years and 53/100,000 in >15 years. The estimated vaccine efficacy was 73.7%. Having any type of socialization behavior (adjusted odds ratio = 6.8, confidence interval: 4.25, 11.4), maternal poor knowledge of measles prevention (adjusted odds ratio = 4.152, confidence interval: 1.226, 8.058), and being unvaccinated (adjusted odds ratio = 7.79, confidence interval: 2.281, 12.63) were associated factors for measles infection.

Conclusion

Poor knowledge of the parents on vaccination and the less effort taken to deliver good attitude toward vaccination are resulting in measles outbreak. However, herd immunity can prevent the outbreak; if not, the community will continue to suffer from mortality and morbidity. A resilient immunization program with sustainable and equitable supply, delivery, monitoring, and evaluation is a fundamental action in prevention of measles outbreak. Increased awareness of vaccination and other prevention measures are also crucial to end the outbreaks.

Measles and Rubella Incidence and Molecular Epidemiology in Senegal: Temporal and Regional Trends during Twelve Years of National Surveillance, 2010-2021

We investigated the epidemiology of measles and rubella infections in Senegal based on data from twelve consecutive years of laboratory-based surveillance (2010−2021) and conducted phylogenetic analyses of circulating measles viruses. Sera from measles-suspected cases were collected and tested for measles and rubella-specific IgM antibodies using enzyme-linked immunosorbent assays (ELISA). Throat swabs were collected from patients with clinically diagnosed measles for confirmation by reverse-transcription polymerase chain reaction (RT-PCR) and viral genotyping. Among 8082 laboratory-tested specimens from measles-suspected cases, serological evidence of measles and rubella infection was confirmed in 1303/8082 (16.1%) and 465/6714 (6.9%), respectively. The incidence of rubella is now low—0.8 (95% CI 0.4−1.3) cases per million people in 2021—whereas progress towards measles pre-elimination targets (<1.0 case per million people per year) appears to have stalled; there were 10.8 (95% CI 9.3−12.5) cases per million people in 2021. Phylogenetic analyses revealed that all Senegalese measles strains belonged to genotype B3. The rubella virus sequence obtained in this study was consistent with genotype 1C. Our national surveillance data suggest that despite their low incidence both measles and rubella remain endemic in Senegal with a concerning stagnation in the decline of measles infections that represents a significant challenge to the goal of regional elimination.

Measles Outbreak Investigation in Guradamole District of Bale Zone, South Eastern Ethiopia, 2021

Background

Method

Results

Conclusion

Risk factors for measles outbreak in Ataq and Habban districts, Shabwah governorate, Yemen, February to May 2018

BACKGROUND

Recent conflict and war in Yemen lead to collapse of the health system, decrease of immunization coverage and spread of many outbreaks. On May 22, 2018, the surveillance officer in Shabwah governorate reported an increased number of suspected measles. On May 24, 2018, a team from Yemen-Field Epidemiology Training Program was sent to investigate. The aims were to describe the outbreak, determine the risk factors for measles infection and recommend control measures.

METHODOLOGY

A descriptive followed by case-control study design (1:2 ratio) were performed. National Measles Surveillance Program case definition and predesigned questionnaire were used to collect data from 73 cases and 146 controls. Attack rate (AR), adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) were calculated. P value < 0.05 was considered as the cut point for significant. Epi info version 7.2 was used.

RESULTS

A total of 73 suspected cases were found. Almost 53% were from Habban district, 63% were males and 56% were among age group < 5 years. The overall AR was 82/100,000 population. Measles was significantly associated with contact with case (aOR = 27.3, 95% CI:1.3-551.7), malnourished children aged 6-60 months (aOR = 24.9, 95% CI;1.9-329.6) and unvaccinated children (aOR = 17.2, 95% CI:2.9-100.7). The six collected blood samples found to be positive for measles IgM.

CONCLUSIONS

Measles outbreak in Ataq and Habban districts was confirmed. Contact with measles cases, malnutrition and un-vaccination were the potential contributing factors of measles outbreak in Shabwah governorate. An urgent vaccination campaign with health education interventions are highly recommended. Reactivation of the outreach immunization services and strengthening surveillance and response systems are top priority to take place at district and governorate levels.

Nanoemulsions: The rising star of antiviral therapeutics and nanodelivery system-current status and prospects

Nanoemulsions (NEs) of essential oil (EO) have significant potential to target microorganisms, especially viruses. They act as a vehicle for delivering antiviral drugs and vaccines. Narrowing of drug discovery pipeline and the emergence of new viral diseases, especially, coronavirus disease, have created a niche to use NEs for augmenting currently available therapeutic options. Published literature demonstrated that EOs have an inherent broad spectrum of activity across bacterial, fungal, and viral pathogens. The emulsification process significantly improved the efficacy of the active ingredients in the EOs. This article highlights the research findings and patent developments in the last 2 years especially, in EO antiviral activity, antiviral drug delivery, vaccine delivery, viral resistance development, and repurposing EO compounds against SARS-CoV-2.

Evaluation of Measles Surveillance Systems in Ginnir District, Bale Zone, Southeast Ethiopia: A Concurrent Embedded Mixed Quantitative/Qualitative Study

Background

Public health surveillance systems should be evaluated periodically to ensure the problems of public health importance are being monitored efficiently and effectively. Despite the widespread measles outbreak in Ginnir district of Ethiopia in 2019, an evaluation of measles surveillance systems has not been conducted. Therefore, we evaluated the performance of measles surveillance systems and key attributes in Ginnir district, Southeast Ethiopia.

Methods

We conducted a concurrent embedded mixed quantitative/qualitative study in August 2019 among 15 health facilities/study units in Ginnir district. The qualitative study involved a purposively selected 15 key-informants. Data were collected using updated guidelines for evaluating surveillance systems based on CDC’s Framework.

Results

Records of 15 study units were reviewed and 15 key informants participated. The structure of surveillance data flow was from the community to the respective upper level. Emergency preparedness and a response plan was available only at the district level. Weekly report completeness and timeliness were 95% and 87% respectively. We found weak supportive supervision and feedback, and no regular analysis and interpretations of surveillance data. The participation of surveillance stakeholders in implementation of the system was good. The surveillance system was found to be useful, easy to implement, representative, and can accommodate and adapt to changing operating conditions. Report documentation and quality of data was poor at lower level health facilities. The stability of the system has been challenged by a shortage of budget, logistics, staff turnover and lack of update trainings.

Conclusion

The surveillance system was acceptable, useful, simple, flexible, and representative. Quality of data, timeliness, and the stability of the system were attributes that require improvement. The overall performance of measles surveillance systems in prevention and control of measles was weak. Hence, regular analysis of data, preparation, and dissemination of epidemiological bulletin, capacity building, and regular supervision and feedback are recommended to enhance performance of the system.