Measles outbreak in Mongolia – FAQs

5 May 2016

OUTBREAK FACTS:

1. When, where and why did the outbreak start?

  • According to the currently available data there is a likelihood that the outbreak started before March 2015.
  • It’s unknown where the outbreak started but the first registered case was reported on 18 March 2015 from Chingeltei District of Ulaanbaatar city.
  • Laboratory results showed that the measles virus genotype identified from the first registered case was similar the measles virus circulating in China. The outbreak started due to presence of:
    • imported measles virus from infected people;
    • susceptible people(those without immunity to measles); and
    • contact between infected and susceptible people in Mongolia.

2. Who is at risk?

Everyone who is not protected against measles virus, i.e.

  • has not received at least two doses of measles vaccine or
  • was never infected with measles virus.

3. What are the latest numbers and how many people including infants have we lost to this outbreak?

The Ministry of Health and Sports reported 105 fatalities in the first four months of the year. Out of those 59 are laboratory-confirmed cases and 46 are clinically confirmed cases. 90 percent of all fatalities are infants up to 8 months of age. In 2016, a total of 23,888 confirmed and suspected cases of measles were reported by the Government.

4. From which geographical area were the most cases registered?

As of beginning of May, the capital city and Uvurkhangai province have reported the highest number of cases. The measles cases were reported in all 21 provinces of Mongolia.

5. Why did so many infants die within the first three months of 2016? Is it directly related to measles?

Globally, measles is still one of the leading causes of death for children less than five years of age despite the availability of a safe and effective vaccine that prevents this deadly disease. The younger the age of a child, the more fatal measles can be. In addition, studies have shown that measles virus infection often results in pneumonia or diarrhea that contribute to the total number of children who die of causes related to measles.

6. Why people who underwent MMR routine immunization still get sick?

  • Age factor
    • On average 89.6% of infants who were vaccinated against measles at 8–9 months develop immunity to measles.
    • On average 99% of infants who were vaccinated at 11–12 months develop immunity to measles.
    • Studies on revaccination in children who failed to respond to their first dose of measles vaccine show that almost all develop immunity after their second dose.
    • Therefore, around 10% of people who underwent “MMR routine immunization" only at 9 months of age may not develop immunity and still get sick. In Mongolia routine measles vaccination is administered at 9 months and 2 years of age.
  • Immunization gap:
    • Although it’s reported that the vaccination coverage rate in Mongolia is very high, i.e. 96% this outbreak demonstrated that there was a considerable immunization gap among certain groups of populations.

7. Why are adults from 18-30 years of age going to be vaccinated in May?

According to the currently available epidemiological analysis, the most affected age groups are people aged 18-30 years old and young infants before they are eligible to receive the first dose of measles vaccine at 9 months of age.

This finding suggests that there is an immunity gap against measles among:

  • people who were born in 1986-1998 (currently 18-30 years of age) during the period of rapid political and socio-economic changes in Mongolia that presented considerable challenges to health sector and
  • newborn infants who are too young to receive the first dose of measles vaccine and are not protected by the immunity that is usually passed from an immune mother to the infant, because the mother may be between the age of 18 and 30 years and may not herself be immune.

The only way to close the immunity gap for both groups is to conduct a vaccination campaign with measles-containing vaccine. Thus, the Government of Mongolia has decided to conduct the supplementary immunization activity for people aged 18-30 years old in May 2016.

8. For how much longer is this outbreak likely to continue?

The upcoming vaccination of young adults from 18-30 years of age will help to contain this outbreak. It’s vitally important for anyone who has not been infected or vaccinated earlier hence are not immune to measles to be vaccinated against measles. Those who do not have immunity against measles are most likely to be affected during this outbreak.

9. What measures are being undertaken to stop this outbreak?

  • improving routine immunization and ensuring vaccination of missed children “zero” in the routine immunization schedule;
  • conducting advocacy, communicating and delivering information and education to public;
  • conducting surveillance including case detection and investigation;
  • isolating suspected cases;
  • diagnosis, treatment and rehabilitation of infected patients;
  • preventing transmission of virus in and via hospitals;

conducting supplementary vaccination with a measles-rubella vaccine (MR-SIA) targeting people aged 18-30 years; and mop-up supplementary vaccination activity (SIA) if needed

10. How is WHO helping Mongolia to contain this outbreak?

  • In 2015:
    • As a leading international public health organization, WHO provided technical expertise through WHO / U.S. Centers for Communicable Diseases Control and Prevention combined missions in April to May 2015 and September 2015 to analyze the situation and make recommendations. WHO provided support for conducting laboratory differential diagnosis, on-the-job supportive supervision, and technical assistance on outbreak investigation.
    • WHO and UNICEF covered operational costs for the mass supplementary vaccination campaign conducted in May to June 2015 for children from 6 months to 6 years.
  • In 2016:
    • WHO and UNICEF continues providing technical support to the Ministry of Health and Sports and will cover technical and operational costs for the upcoming May 2016 vaccination campaign targeting persons from 18 to 30 years of age.

11. What has WHO recommended to the Government to contain the outbreak?

WHO recommendations were given in two main directions.

To contain the current outbreak:

  • reorganize management of suspected measles cases to prevent transmission of disease via hospitals;
  • improve case detection, epidemiologic investigation and outbreak response: isolation procedures, contact tracing, identification of immunity gaps, vaccination of contacts, etc. in all sub-districts of Ulaanbaatar, provinces and sub-provinces;
  • vaccinate children from 9 months to 5 years of age;
  • vaccinate 24-29 years old, 18-23 years old and 29-34 years old with measles-rubella vaccine;
  • vaccinate 13-17 years old with measles-rubella vaccine;
  • vaccinate children aged 6-9 months with measles-containing vaccine (MCV-0); and
  • vaccinate healthcare workers, military personnel and institutionalized people with measles-rubella vaccine.

For prevention and preparedness for future outbreaks:

  • further investigate the current outbreak to identify risk factors to measles infection and document the current outbreak;
  • finalize (i) the new National Plan for Measles & Rubella Elimination in Mongolia in 2016-2020 and (ii) the National Red or Watery Eyes Procedures for Preparedness for and Response to Infectious Diseases Outbreaks;
  • conduct a vaccine-preventable diseases (VPD) surveillance review to assess system and assist in developing strategy to streamline overall surveillance;
  • strengthen communication through periodic (monthly) meetings of staff from the two surveillance systems (Early Warning And Response and VPD) and the measles laboratory, to ensure the early detection and confirmation of measles cases;
  • enforce the case-based measles surveillance including active case detection and investigation and sample collection and testing and integrate surveillance systems to improve surveillance as well as laboratory confirmation and thus meeting performance indicators for verification;
  • conduct a national Expanded Programme on Immunization (EPI) review and population immunity assessment (serosurvey and coverage survey) and determine reasons for miss vaccination, and improve measles-containing vaccine, first dose (MCV-1) and measles-containing vaccine, second dose (MCV-2) coverage monitoring;
  • establish a programme on school entry check of vaccination status followed by catch-up vaccination at entry to schools and colleges;
  • establish a policy that all new healthcare workers, military personnel and institutionalized population to be vaccinated at entry;
  • consider implementation of follow-up measles-rubella supplementary vaccination against birth cohorts born after 2015 based on coverage monitoring

ON SUPPLEMENTARY MEASLES-RUBELLA VACCINATION:

1. What are the dates for the supplementary measles vaccination for people from 18-30 years of age?

12-25 May 2016.

2. How many doses will be administered during the measles vaccination campaign?

One dose to each age-eligible person.

3. Where will the vaccination be administered?

At Family Health Centers, hospitals, District Health Centers, in universities and at work places.

4. Is having an additional, booster, shot of a measles vaccine safe?

Yes, it’s safe to receive the measles vaccine whether you were previously vaccinated or not. However, there should be at least one month between doses of measles vaccine.

5. Why not only measles but measles-rubella (MR) combined vaccine will be administered?

Mongolia carried out a nation-wide mass vaccination campaign with MR vaccine in 2012 targeting children aged 3-14 years. Hence only people who were born after 1998 were given a chance to be immunized by rubella containing vaccine

Since the coming supplementary vaccination campaign will use Measles and Rubella vaccine (MR), the campaign will have a chance to give people aged 18-30 years immunity against rubella and thus prevent rubella infection and future rubella outbreak as well and congenital rubella syndrome (CRS).

6. Are there any contraindications for MR vaccine to be administered in May for 18-30 year olds?

The supplementary vaccine to be administered in May for 18-30 year olds is a measles-rubella combined vaccine. Because of a theoretical, but never demonstrated, teratogenic risk (risk of causing congenital defects to fetus), rubella vaccination of pregnant women should be avoided in principle. Women who intend to become pregnant should be advised to delay for 1 month following rubella vaccination. Women should be asked about the possibility of early pregnancy prior to rubella vaccination. If one is undergoing an acute condition of any other illnesses and/or has a previous history of allergic reaction to any vaccines or known allergic condition to any of the vaccine ingredients this person should not be vaccinated.

GENERAL FACTS ABOUT MEASLES VIRUS:

1. What is measles?

Measles is a highly contagious, serious disease caused by a virus. In 1980, before widespread vaccination, measles caused an estimated 2.6 million deaths each year. It remains one of the leading causes of death among young children globally, despite the availability of a safe and effective vaccine. Approximately 122 000 people died from measles in 2012 – mostly children under the age of five.

2. What are the symptoms?

The first sign of measles is usually a high fever. The fever begins about 10 to 12 days after exposure to the virus and lasts four to seven days. A runny nose, a cough, red and watery eyes, and small white spots inside the cheeks can develop in the initial stage. After several days, a rash erupts, usually on the face and upper neck. Over about three days, the rash spreads, eventually reaching the hands and feet. The rash lasts for five to six days, and then fades.

3. What is the risk of complications and how high are chances of developing complications?

  • Most measles-related deaths are caused by complications associated with the disease. Complications are more common in children under the age of five, or adults over the age of 20. The most serious complications include blindness, encephalitis (an infection that causes brain swelling), severe diarrhoea and related dehydration, ear infections, or severe respiratory infections such as pneumonia. Up to 10% of measles cases result in death among populations with high levels of malnutrition and a lack of adequate health care. Women infected while pregnant are also at risk of severe complications, including miscarriage and preterm delivery.
  • Severe measles is more likely among poorly nourished young children, especially those with insufficient vitamin A, or whose immune systems have been weakened by HIV/AIDS or other diseases.

4. Who are the most vulnerable to measles virus?

Unvaccinated young children are at the highest risk for measles and its complications, including death. Unvaccinated pregnant women are also at risk. Any person who is not immune to measles can become infected. Most often, this includes people who did not receive two doses of measles vaccine.

5. When was the first vaccine introduced in the world and in Mongolia?

  • Most live, attenuated measles vaccines originate from the Edmonston strain of measles virus, isolated by Enders and Peebles in 1954. Well known vaccine strains derived from the original Edmonston isolate include the Schwarz, the Edmonston-Zagreb, the AIK-C and the Moraten strains, all in use since the 1960s.
  • One-dose schedule for measles vaccination started in Mongolia in 1973 as a part of the national routine vaccination programme.

6. Who should get the measles vaccine?

According to the current national routine vaccination schedule of Mongolia, a child should be vaccinated with measles-containing vaccine at 9 months and at 2 years of age. In May 2016, Mongolian citizens aged 18 to 30 years should get a supplementary measles vaccination dose.

7. How effective is the MMR vaccine imported to Mongolia from the “Serum Institute” of India?

All vaccines currently used for childhood immunizations in Mongolia are pre-qualified by WHO for its quality and effectiveness and procured through UN procurement channel based on international bidding.

8. Are the vaccines paid by the state budget?

Yes, the measles-containing vaccine currently being used for the routine childhood vaccination is paid from the state budget. Measles-rubella vaccine to be used for upcoming supplementary vaccination campaign targeting persons 18 to 30 years is also paid for by the Government of Mongolia.

9. Is a person who was once sick with measles at risk of contracting the virus again?

No, if a person has natural infection with measles virus, then he or she has lifelong immunity against measles, thus no risk of contracting the virus again.

10. How high is the risk of people over 40 who never were sick with measles to get infected during the current outbreak?

If a person did not get vaccinated with two doses of measles-containing vaccines in the past, then the risk of infection during the current outbreak is high.

11. Can a measles vaccine be administered to a person of any age?

Everyone above 6 months of age (except for pregnant women) are eligible to get the vaccine.

12. Can an adult person pay for a measles vaccine privately and get a shot to prevent him/her from being affected by the measles outbreak?

Yes, the vaccine is available in the voluntary vaccination cabinet of the Outpatient’s Clinic of the National Centre for Communicable Diseases.

WHAT TO DO IF YOU SUSPECT YOUR FAMILY MEMBER HAS MEALES:

  • The first signs of possible measles are fever, runny nose, cough, red or watery eyes or eyes bothered by light during the second week of exposure to suspected measles cases. Appearance of a rash usually occurs a day or two after the other symptoms start.
  • Call to 100 hotline or place an emergency call for a doctor from the Family Health Centre.
  • At home, a suspected measles case should only be permitted contact with immediate family members until five days after the rash appears. Communicability greatly decreases after the second day of rash (suspected measles cases should not be hospitalized unless absolutely necessary because of the high risk of transmission in the hospital. In hospitals, patients with suspected measles should be isolated from the onset of symptoms through the fifth day of rash).
  • Contacts are defined as all persons living in a household or other close quarters with the case during the infectious period (five days before to five days after the onset of the rash).
  • Contacts without evidence of measles immunity should immediately be vaccinated. They should also be instructed about the symptoms of measles prodrome and told to avoid contact with other persons for two full weeks after exposure.
  • If less than 14 days have elapsed since the case’s rash began, all contacts should receive the isolation instructions whether or not they have been immunized.
  • During the second week after exposure, at the first sign of possible measles (fever, runny nose, cough, or eyes bothered by light), the contact should be instructed to stay at home. The contact should not attend school, preschool, work, church, clubs, meetings, parties, babysitting groups, etc. If the illness is measles, it will become apparent in one or two days by the severity of the illness and the presence of a rash. Parents should be advised to notify the health care provider immediately upon rash onset.
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