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88thth Global Measles and Rubella Global Measles and Rubella LabNet Meeting, Sept 2010 LabNet Meeting, Sept 2010 Key Recommendations Key Recommendations
GLOBAL MEASLES AND RUBELLA MANAGEMENT GLOBAL MEASLES AND RUBELLA MANAGEMENT MEETINGMEETING
15-17 March 201115-17 March 2011
Salle B, WHO Headquarters, Geneva, SwitzerlandSalle B, WHO Headquarters, Geneva, Switzerland
David Featherstone
EPI / IVB
WHO Geneva
OutlineOutline
What are the challenges for the LabNet?What are the challenges for the LabNet?– Implications for achieving Elimination Quality IndicatorsImplications for achieving Elimination Quality Indicators– Reporting dataReporting data– Quality AssuranceQuality Assurance– New Laboratory ProceduresNew Laboratory Procedures– Funding Funding – Summary Summary
WHO Vaccine Preventable Disease Lab Network2
33 3 WHO Vaccine Preventable Disease Lab Network3
Global LabNet Meeting Global LabNet Meeting Participants Participants
Implications for LabNet in achieving Implications for LabNet in achieving Elimination Indicators Elimination Indicators (WER No 49, 2010, 85, 490- (WER No 49, 2010, 85, 490-495)495)
ELISA IgM testingELISA IgM testing::– ≥ ≥ 2/100,000 (non-measles rash/fever cases) per year & ≥ 2/100,000 (non-measles rash/fever cases) per year & ≥
80% serum samples collected 80% serum samples collected Workload increase estimated extra ~50,000 cases / yrWorkload increase estimated extra ~50,000 cases / yr Mainly Pakistan and India moving to case based Mainly Pakistan and India moving to case based
surveillancesurveillance India planning 3 new labs 2011 (~$100,000)India planning 3 new labs 2011 (~$100,000) LabNet has proven surge capacity LabNet has proven surge capacity
– Measles IgM cost ~ $ 3 -11 per sample (depending on Measles IgM cost ~ $ 3 -11 per sample (depending on batch size)batch size)
– Rubella IgM cost ~ $ 4.50 -17 per sampleRubella IgM cost ~ $ 4.50 -17 per sample
WHO Vaccine Preventable Disease Lab Network4
Implications for LabNet in achieving Implications for LabNet in achieving Elimination Indicators Elimination Indicators (WER No 49, 2010, 85, 490-(WER No 49, 2010, 85, 490-495)495)
Virus detection: Virus detection: – Measles elimination: Measles elimination: The The absence of absence of
endemic measles cases: endemic measles cases: – Re-establishment of endemicityRe-establishment of endemicity: continuous : continuous
transmission of indigenous measles virus for a transmission of indigenous measles virus for a period of > 12 months: period of > 12 months:
– >80% of laboratory-confirmed measles >80% of laboratory-confirmed measles outbreaks have adequate samples for virus outbreaks have adequate samples for virus characterization in an accredited labcharacterization in an accredited lab
WHO Vaccine Preventable Disease Lab Network5
Current challenges for improving Current challenges for improving molecular surveillancemolecular surveillance
African region: African region: – Building molecular capacity in Uganda and CIVBuilding molecular capacity in Uganda and CIV
Molecular surveillance gaps: Molecular surveillance gaps: – Sequencing capacity available but limited sample Sequencing capacity available but limited sample
collection for virus detectioncollection for virus detection– Enhanced molecular surveillance using Oral fluid Enhanced molecular surveillance using Oral fluid
Trials in India, Benin, CIV, Kenya, Malawi and ZimbabweTrials in India, Benin, CIV, Kenya, Malawi and Zimbabwe
WHO Vaccine Preventable Disease Lab Network6
Molecular surveillance Molecular surveillance recommendationsrecommendations
Reference and sequencing laboratories Reference and sequencing laboratories – determine their capacity to reach surveillance indicators determine their capacity to reach surveillance indicators – determine the additional resources neededdetermine the additional resources needed
Laboratory and field surveillance programmes Laboratory and field surveillance programmes – collaborate to enhance molecular surveillancecollaborate to enhance molecular surveillance
Greater molecular capacity needed with documented Greater molecular capacity needed with documented accuracyaccuracy– training programmestraining programmes– molecular proficiency programme establishedmolecular proficiency programme established
WHO Vaccine Preventable Diseases Lab Network9
Member states reporting
(expected)Specimens
received
Measles 2010
Rubella 2010
WHO region Tested Positive Tested Positive
AFR 31 (46) 18,151 18,151 6,757 12,605 1,963
AMR 30 (35) 11,582 5,347 22 5,678 134
EMR 21 (21) 12,242 11,615 3,873 9,760 1,042
EUR 46 (53) 27,110 22,325 4,994 21,590 936
SEAR 11 (11) 5,284 4,968 1,697 3,524 1,547
WPR 12 (27) 16,897 15,658 4,141 13,617 3,606
Total 153 (193) 91,266 78,064 21,484 66,774 9,228
* As of Jan 2011
Data Issues:Data Issues: Measles and Rubella Laboratory Measles and Rubella Laboratory Tested Cases Tested Cases ReportedReported to WHO HQ 2010* to WHO HQ 2010*
Data source: surveillance DEF fileData in HQ as of 8 Jan 2011
WHO Vaccine Preventable Diseases Lab Network10
Member states reporting
(expected)Specimens
received
Measles 2010
Rubella 2010
WHO region Tested Positive Tested Positive
AFR 31 (46) 18,151 18,151 6,757 12,605 1,963
AMR 30 (35) 11,582 5,347 22 5,678 134
EMR 21 (21) 12,242 11,615 3,873 9,760 1,042
EUR 46 (53) 27,110 22,325 4,994 21,590 936
SEAR 11 (11) 5,284 4,968 1,697 3,524 1,547
WPR 12 (27) 16,897 15,658 4,141 13,617 3,606
Total 153 (193) 91,266 78,064 21,484 66,774 9,228
* As of Jan 2011
Data Issues:Data Issues: Measles and Rubella Laboratory Measles and Rubella Laboratory Tested Cases Tested Cases ReportedReported to WHO HQ 2010* to WHO HQ 2010*
Data source: surveillance DEF fileData in HQ as of 8 Jan 2011
South Africa outbreak 18,359 laboratory confirmed 2010
~ 50,000 / year (2008)
China not reporting
22,037 from Country reports
Data reporting: RecommendationsData reporting: Recommendations
LabNet encouraged to work with their national LabNet encouraged to work with their national surveillance programmes to reconcile surveillance programmes to reconcile laboratory and field surveillance data laboratory and field surveillance data
Data sent to WHO according to agreed upon Data sent to WHO according to agreed upon reporting requirementsreporting requirements
WHO Vaccine Preventable Disease Lab Network
WHO Global genotype databases: Current WHO Global genotype databases: Current StatusStatusViruses submitted dating from 1954 to 2011 Viruses submitted dating from 1954 to 2011
WHO Database
No. of viruses
Genotypes Countries and
Territories
WHO Regions
Proportion with GenBank entries
Measles 8912 23 + 1 prov.
131 6 37%
Rubella 773 9+ 4 prov.
44 6 36%
Data as of 28 Feb 2011
13
N – 450bp – 5542 sequences N – full – 5 sequencesH – full – 503 sequences
MeaNS database (HPA/WHO)
0
200
400
600
800
1000
1200
1400
1600
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
WPR
SEAR
EUR
EMR
AMR
AFR
Measles Genotype data submitted to WHO Measles Genotype data submitted to WHO Database Database
WHO Vaccine Preventable Disease Lab Network
6
4
17
3
24
8
4
2
22
122
9
10
3
20
10
9
3
11
3
13
92
19
9
4
21
10
17
3
Number of countries submitting virus data per region
Year of onsetYear of onset
26
31
3039
58
55
55
57
64
10
Total number of countries submitting virus data per year
Nu
mb
er
of
vir
use
s su
bm
itte
dN
um
ber
of
vir
use
s su
bm
itte
d
14
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. ©WHO 2011. All rights reserved.
2010 incidence
No data reported
B2
B3
D4
D5
D8
D9
H1
Incidence:(per 100'000)
<0.1
≥0.1 - <1
≥1 - <5
≥5
Genotype:West Africa inset West Europe inset
2010 Distribution ofmeasles genotypes
5
1
Chart proportional tonumber of genotypes
China: Measles isolates and genotyping results, 2009
D4 (1 case)D9 (1 case)
d11 (17 cases)
Yunnan
2009: 270 cases H1a measles virus reported to database2009: 270 cases H1a measles virus reported to database
Unpublished data provided by Xu Wenbo
1717 17
Recognition of new genotypes Recognition of new genotypes
d11d11 MVi/Menglian.Yunnan.CHN/47.09/1. Virus to be provided by China MVi/Menglian.Yunnan.CHN/47.09/1. Virus to be provided by China CDC. CDC.
Genotype B3 sequences from Libya, Tunisia and Sudan should be Genotype B3 sequences from Libya, Tunisia and Sudan should be considered as a considered as a third cluster in genotype B3third cluster in genotype B3. Virus to be provided by . Virus to be provided by Institut Pasteur de Tunis. Institut Pasteur de Tunis.
Reference viruses for Reference viruses for Rubella genotypes 1h, 1i, and 1j Rubella genotypes 1h, 1i, and 1j have been have been identified. These viruses to deposited in the WHO rubella virus strain identified. These viruses to deposited in the WHO rubella virus strain banksbanks
The recent changes in the list of recognized rubella and measles The recent changes in the list of recognized rubella and measles genotypes should be published in the WERgenotypes should be published in the WER
A steering committee to be formed to review and refine the protocols for A steering committee to be formed to review and refine the protocols for accepting and distributing sequence information via MeaNS and the WHO accepting and distributing sequence information via MeaNS and the WHO DatabaseDatabase
WHO should develop a mechanism for rapidly notifying LabNet of WHO should develop a mechanism for rapidly notifying LabNet of important developments such as detection of a new lineage or genotypeimportant developments such as detection of a new lineage or genotype
WHO Vaccine Preventable Disease Lab Network17
D6 strains in Germany and Belarus
1 month
6 months
N gene NPH gene
UKR
UKRBEL
Data Provided by Luxemburg Laboratory Data Provided by Luxemburg Laboratory
Recommendation: Recommendation:
Select laboratories to Select laboratories to evaluate and identify evaluate and identify when appropriate to when appropriate to implementimplement
LabNet Proficiency test LabNet Proficiency test performance-Measles IgM performance-Measles IgM
PanelsPanelsPanel No.Panel No. ≥≥ 90% correct90% correct
(Pass)(Pass)
00801 n=46 (2001)00801 n=46 (2001) 96%96%
00702 n=17 (2002)00702 n=17 (2002) 88%88%
01002 n=66 (2003)01002 n=66 (2003) 95%95%
00703 n=99 (2004)00703 n=99 (2004) 90%90%
00704 n=115 (2005)00704 n=115 (2005) 94%94%
00508 n=142 (2006)00508 n=142 (2006) 98%98%
00607 n=164 (2007)00607 n=164 (2007) 98%98%
00705 n=173 00705 n=173 (2008)(2008) 99%99%
00805 n= 171 00805 n= 171 (2009)(2009) 98%98%
00905 n= 220 00905 n= 220 (2010)(2010) 99%99%
Quality Assurance RecommendationsQuality Assurance Recommendations
More comprehensive analysis of IgM proficiency More comprehensive analysis of IgM proficiency testing and reporting testing and reporting
Introduction of proficiency test for molecular Introduction of proficiency test for molecular technitechniques ques
More comprehensive training & post training More comprehensive training & post training assessmentsassessments
WHO Vaccine Preventable Disease Lab Network22
2424 24
Point of care rapid measles assayPoint of care rapid measles assay
The measles rapid point The measles rapid point of care (POC) shows of care (POC) shows promising sensitivity and promising sensitivity and specificity compared with specificity compared with detection of IgM in serumdetection of IgM in serum
WHO Vaccine Preventable Disease Lab Network24
POC to be further POC to be further validated using oral fluid validated using oral fluid samples collected under samples collected under routine field conditions routine field conditions
Documentation of new proceduresDocumentation of new procedures
WHO Vaccine Preventable Disease Lab Network
Alternative samples to serum for measles and rubella
New sequencing primers for measles and rubella
Real time PCR; M & R
Validated and in process of implementation In process of validation
Rapid Point of care assays
M & R PCR QC M & R PCR QC programmeprogramme
Standards for Standards for measles measles serosurveyserosurvey
25
QC for Oral QC for Oral fluidfluid
$0
$200,000
$400,000
$600,000
$800,000
$1,000,000
$1,200,000
$1,400,000
$1,600,000
Lab Support Meetings Consumables Kits
Training Travel Equipment
Shortfall
Funds Identified 2011
Current LabNet Estimated CostsCurrent LabNet Estimated Costs
WHO Vaccine Preventable Disease Lab Network27
Estimated shortfall
$1,300,000
Funding recommendations Funding recommendations
LabNet should endeavour to find additional LabNet should endeavour to find additional resources and new partnersresources and new partners
Countries encouraged to include laboratory Countries encouraged to include laboratory support in their surveillance budgetssupport in their surveillance budgets
Additional funds for training, to: Additional funds for training, to: – Maintain the current high level of LabNet Maintain the current high level of LabNet
performanceperformance– Strengthen sequencing capacityStrengthen sequencing capacity
Summary Summary
LabNet has capability to meet increased LabNet has capability to meet increased surveillance needssurveillance needs– Some capacity will need to be developed Some capacity will need to be developed
Capacity building and extra testing comes at Capacity building and extra testing comes at a cost, not all of which is realised a cost, not all of which is realised