Development of the World Health Organization Measles Programmatic Risk Assessment Tool Using Experience from the 2009 Measles Outbreak in Namibia

In the World Health Organization (WHO) African region, reported measles cases decreased by 80% and measles mortality declined by 88% during 2000-2012. Based on current performance trends, however, focused efforts will be needed to achieve the regional measles elimination goal. To prioritize efforts to strengthen implementation of elimination strategies, the Centers for Disease Control and Prevention and WHO developed a measles programmatic risk assessment tool to identify high-risk districts and guide and strengthen program activities at the subnational level. This article provides a description of pilot testing of the tool in Namibia using comparisons of high-risk districts identified using 2006-2008 data with reported measles cases and incidence during the 2009 outbreak. Of the 34 health districts in Namibia, 11 (32%) were classified as high risk or very high risk, including the district of Engela where the outbreak began in 2009. The district of Windhoek, including the capital city of Windhoek, had the highest overall risk score-driven primarily by poor population immunity and immunization program performance-and one of the highest incidences during the outbreak. Other high-risk districts were either around the capital district or in the northern part of the country near the border with Angola. Districts categorized as high or very high risk based on the 2006-2008 data generally experienced high measles incidence during the large outbreak in 2009, as did several medium- or low-risk districts. The tool can be used to guide measles elimination strategies and to identify programmatic areas that require strengthening.

Measles immunity among pregnant women aged 15-44 years in Namibia, 2008 and 2010

Background:

Namibia experienced a large measles outbreak starting in 2009, with 38% of reported cases in adults, including women of reproductive age. Population immunity was assessed among pregnant women to determine whether immunization activities were needed in adults to achieve measles elimination in Namibia.

Methods:

A total of 1708 and 2040 specimens sampled from Namibian pregnant women aged 15–44 years who were included in the 2008 and 2010 National HIV Sentinel Survey, respectively, were tested for measles immunoglobulin G antibody. The proportion of women seropositive overall and by 5-year age strata was determined, and factors associated with seropositivity were analyzed by logistic regression, including age, facility type, gravidity, HIV status, and urban/rural setting. Seropositivity in 2008 versus 2010 was compared.

Results:

In both analysis years, measles seropositivity was lower in 15–19-year-olds (77%) and 20–24-year-olds (85–87%) and higher in 25–44-year-olds (90–94%) (2008, p < 0.001; 2010, p < 0.001). Overall measles seropositivity did not differ between 2008 (87%) and 2010 (87%) (p = 0.7). HIV status did not affect seropositivity.

Conclusions:

Late in a large measles outbreak, 13% of pregnant women in Namibia, and almost one in four 15–19-year-old pregnant women, remained susceptible to measles. In Namibia, immunization campaigns with measles-containing vaccine should be considered for adults.

Poliovirus immunity among pregnant females aged 15-44 years, Namibia, 2010

BACKGROUND

Poliovirus (PV) antibody seroprevalence studies assess population immunity, verify an immunization program's performance and vaccine efficacy, and guide polio eradication strategy. Namibia experienced a polio outbreak among adults in 2006, yet population seroimmunity was unknown.

METHODS

We tested 2061 specimens from Namibian pregnant females aged 15-44 years for neutralizing antibody to PV types 1-3 (PV1-3); all females were sampled during the 2010 National HIV Sentinel Survey. We determined the proportion of females seropositive for PV antibody by 5-year age strata, and analyzed factors associated with seropositivity, including age, gravidity, human immunodeficiency virus (HIV) infection status, residence, and antiretroviral treatment, by log-binomial regression.

RESULTS

The seroprevalence was 94.6% for PV1, 97.0% for PV2, and 85.1% for PV3. HIV-positive females had significantly lower seroprevalence than HIV-negative females for PV1 (91.8% vs 95.3%; P<.01) and PV3 (80.0% vs 86.1%; P<.01) but not for PV2 (96.4% vs 97.1%; P=.3). The prevalence ratio of seropositivity for HIV-positive females versus HIV-negative females was 0.95 (95% confidence interval [CI], .92-.98) for PV1, 0.99 (95% CI, .97-1.01) for PV2, and 0.92 (95% CI, .87-.96) for PV3.

CONCLUSIONS

Despite relatively high PV seroprevalence, Namibia might remain at risk for a PV outbreak, particularly in lower-seroprevalence populations, such as HIV-positive females. Namibia should continue to maintain high routine polio vaccination coverage.

Maternal, fetal, and neonatal outcomes associated with measles during pregnancy: Namibia, 2009-2010

BACKGROUND

Previous studies of maternal, fetal, and neonatal complications of measles during pregnancy suggest the possibility of increased risk for morbidity and mortality. In 2009-2011, a nationwide laboratory-confirmed measles outbreak occurred in Namibia, with 38% of reported cases among adults. This outbreak provided an opportunity to describe clinical features of measles in pregnant women and assess the relative risk for adverse maternal, fetal, and neonatal outcomes.

METHODS

A cohort of pregnant women with clinical measles was identified retrospectively from 6 district hospitals and clinics over a 12-month period. Each pregnant woman with measles was matched with 3 pregnant women without measles, randomly selected from antenatal clinic registers at the same hospital during the same time interval. We reviewed hospital and clinic records and conducted in-person interviews to collect demographic and clinical information on the pregnant women and their infants.

RESULTS

Of 55 pregnant women with measles, 53 (96%) were hospitalized; measles-related complications included diarrhea (60%), pneumonia (40%), and encephalitis (5%). Among pregnant women with known human immunodeficiency virus (HIV) status, 15% of those without measles and 19% of those with measles were HIV positive. Of 42 measles-related pregnancies with known outcomes, 25 (60%) had ≥1 adverse maternal, fetal, or neonatal outcome and 5 women (12%) died. Compared with 172 pregnancies without measles, after adjusting for age, pregnancies with measles carried significantly increased risks for neonatal low birth weight (adjusted relative risk [aRR] = 3.5; 95% confidence interval [CI], 1.5-8.2), spontaneous abortion (aRR = 5.9; 95% CI, 1.8-19.7), intrauterine fetal death (aRR = 9.0; 95% CI, 1.2-65.5), and maternal death (aRR = 9.6; 95% CI, 1.3-70.0).

CONCLUSIONS

Our findings suggest that measles virus infection during pregnancy confers a high risk of adverse maternal, fetal, and neonatal outcomes, including maternal death. Maximizing measles immunity among women of childbearing age would decrease the incidence of gestational measles and the attendant maternal, fetal, and neonatal morbidity and mortality.