Measles and Rubella Surveillance in the time of Zika: Brazil

1. Measles and Rubella Surveillance in the time of Zika: Brazil Sergio Nishioka Department of Communicable Disease Surveillance, Ministry of Health, Brazil 23 June 2016

2. Case definitions • Measles – suspected casePatientwithfeverplusmaculopapularrashpluscoughand/orcoryza and/orconjunctivitis, independentof age andvaccination • Rubella – suspected case Patientwithfeverplusmaculopapularrashplus (retroauricular and/or occipital and/or cervical) lymphadenopaty, independentof age andvaccination • CRS – suspected case Newborn, infantorchilduntil 12 monthsof age whosemotherwas a suspected case ofrubellaorcontactof a confirmedrubella case and/orwhohasthefollowingclinicalsignsorcomplications: congenitalcataract/glaucoma and/orcardiopathy (persistanceofductusarteriosus, pulmonarystenosis, aorticstenosis) and/ordeafness

3. Case confirmation and comments • Case confirmation For MEASLESand RUBELLA: laboratory diagnosis, epidemiological link or clinical criteria (during outbreaks) For CRS: laboratory diagnosis or epidemiological link • Comments • The definition for suspected measles cases has been considered easier to handle during outbreak investigations than the more sensitive definition restricted to fever and rash • In 2016, until EW18 there were 1.18 million reported suspected cases of dengue in Brazil • Large numbers of individuals with fever and rash due to dengue fever have been observed in Brazil long before the introduction of Zika • Most doctors have never seen measles cases

4. Measles and rubella cases __________________________________________________________________ Year Reports / cases ________________________________________ 2013 2014 2015 __________________________________________________________________ Total no. reports 6371 7940 6968 Confirmedmeasles cases 220 876 214 Laboratory 819 200 Clinical 57 14 Confirmedrubella cases 0 1* 0 Discarded 6151 7064 6754 Laboratory 5752 6629 6261 Clin / epi 194 183 362 Clinical 128 190 100 Vaccine link 57 62 31 __________________________________________________________________ *Imported case fromthePhilippines; no secondary case

5. MR outbreakinvestigations - Additionalinfo • Pernambuco outbreak (03/2013 – 03/2014) • 226 cases • 153,741 reviewedcharts • Ceará outbreak (12/2013 – 07/2015) • 1052 cases • 504,829 reviewedcharts • 15,317 (3%) out of 487,880 dengue-negsamplestested for M&R (2012 – 2015) – allnegative • 940 (11%) out of 8586 chikungunya-negsamplestested for M&R (2014 – 2015) – allnegative

6. Zika • SUSPECTED CASE: Patientswhohavepruriginousmaculopapularrashplusatleast TWO ofthefollowingsignsandsymptoms: Fever OR Non-pruriginousConjunctivalHyperemia OR Polyarthralgia OR Periarticular swelling • CONFIRMED CASE: suspected case withoneofthefollowing positive tests for thediagnosisofZika: Viral isolation; Detectionof viral RNA RT-PCR; IgMantibodies • Case definition for Zika-associatedmicrocephaly • In Brazil, thesurveillance is on “microcephalyand/or CNS abnormalitiessuggestiveofcongenitalinfection in fetuses, abortedfetuses, stillborn babies andnewborns” • Sofaronly a small proportionofsuspected cases havehadlaboratoryconfirmation for Zika

7. Reported Zika cases, Brazil, 2016, EW 1 to 15

8. Zika cases by age groupandgender, Brazil, 2015-2016

9. Zika positive testdistributionbytrimesterofpregnancy(until 5 May 2016)

10. Impact of Zika on MR surveillance - 1 • Was MR surveillance system used as a platform for Zika surveillance? If yes, why? How was this done? OnceZikaviruswasidentified as the cause oftheoutbreakofexanthemathousillness in NE BrazilthisdiseasewasincludedamongthoseunderthesupervisionoftheNational Dengue ControlProgram, which is separatedfromthe MR Surveillance in theMoHorganigram. • Change in case definition? Investigations? No change in the MR case definitions. TheclinicalmanifestationsofZika are more similar to measlesthan dengue is. MostZika cases wouldbeincluded in theBrazilian MR case definition. However, dengue is still much more commonthanZika in the country as a whole.

11. Impact of Zika on MR surveillance - 2 • Laboratory testing algorithm change? Tests for chikungunya and Zika (RT PCR) became available recently and have been added to the algorithm • Laboratory resources? Increased demand for testing, need for training and for lab personnel

12. Negative impact on MR surveillance? • Has MR surveillance suffered? After microcephaly cases started to be reported and became a priority the surveillance of all other communicable diseases was affected • What steps taken to address this? MR surveillance activities have been maintained but interaction with Zika and microcephaly surveillance teams needs improvement • Was lab overwhelmed? Yes, at regional and some reference labs before Zika was identified, for the differential diagnosis. After the microcephaly cases, priority given to Zika has affected time to perform the tests in regional and some reference labs.

13. Zika microcephaly and CRS • Has CRS platform helped with Zika microcephaly surveillance? If yes, how was this done? Yes, regarding the differential diagnosis of TORCH in the newborn. However, the surveillance system adopted in Brazil goes beyond that as it includes also pregnant women, abortions and stillbirths.

14. Lessons learnt • How has Zika surveillance improved or hurt M/R/CRS surveillance? “Microcephaly surveillance” is likely to improve CRS surveillance. The (so far) poor interaction between Zika surveillance and MR surveillance teams at country and state levels has not helped MR surveillance. • What lessons have been learnt from Zika on how to ensure strong MR surveillance during competing health priorities? • What lessons have been learnt from Zika on how to build on M/R/CRS platform in emergency situations? Zika may be seen (so far) as a missing opportunity to improve MR surveillance MR surveillance needs to adapt to new times In Brazil, nowadays, it should be more integrated with the dengue / chikungunya / Zika surveillance Educate clinicians on clinical definitions of measles and rubella (to be lab confirmed) and better interaction with primary care

15. Thankyou sergio.nishioka@saude.gov.br