Module 3: Detecting and Confirming Measles Outbreaks: World Health Organization Geneva, Switzerland

Module 3: Detecting and
confirming measles
outbreaks
World Health Organization
Geneva, Switzerland
WORLD
© World HEALTH
Health Organization 2021 – AfterSLIDE
ORGANIZATION Action 1Review PAGE 1 (Dec-21)
Detecting and confirming measles outbreaks
• National surveillance systems quickly detect and notify public

health officials, epidemiologists and response teams of a
possible measles or rubella outbreak.
• WHO and countries have established case definitions to
identify suspected and clinical cases.
• Prior to deploying to an outbreak, you will need to know the
WHO surveillance standards for VPD as well as the national
case definitions.
• You will also need to know the national procedures for
detecting, confirming and testing measles and rubella cases.
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Detecting and confirming measles outbreaks
At the end of this module, you will be

able to:
• detect and confirm measles cases to
ensure proper case management and
enable implementation of appropriate
public health strategies to control
further transmission; and
• identify components of the outbreak
detection and confirmation process. Photo: CDC/Alissa Eckert
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Signal detection
• Signals are data or information that may

represent an event of potential acute risk to All signals, regardless
human health and require a rapid response. of their source, serve
• Signals are detected through a sensitive high- to alert public health
quality measles-rubella surveillance system or authorities to
through national early warning and response suspected cases and
system (EWARS). need to be verified
• Signals of measles-like illness may consist of and investigated to
individual reports or clusters of fever and rash determine if they truly
cases or death, notified through event-based represent measles.
or community-based surveillance systems.
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Measles surveillance systems
• All countries should have well functioning case-based
measles and rubella surveillance systems that satisfy
standard surveillance performance indicators.
• Surveillance should be nationwide and include all
health facilities (private and public), with zero
reporting.
• Aggregate surveillance systems report non-individual
data (e.g., number of cases).
• Case-based surveillance systems report individual
case investigation data, including laboratory and case
classification.
Photo: CDC/NIP/Barbara Rice
• Measles surveillance must be case-based in
elimination mode.
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Surveillance resources
Refer to the WHO

Surveillance
Standards for VPD
and the WHO Guide
on Early detection,
assessment and
response to acute
public health events
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Event verification
• A signal detected through community-based

surveillance will need to be verified. Meeting a
• Verification is essential and often done remotely by suspected case
central level staff who contact local health staff definition does not
where the event has occurred – are they seeing confirm that the
increased cases? Signs/symptoms? case is measles –
• Verification allows you to collect information on further investigation
number of people affected; place/date of occurrence; is needed, including
presenting symptoms, laboratory findings, etc. laboratory
confirmation and
• All measles cases first identified through signal epidemiologic
detection systems should enter measles case-based investigation.
reporting systems – using standard definitions.
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Case definitions and case classifications
• There are two case definitions used for case finding –

suspected measles case and clinical measles case (see Module
1).
• If a case meets the definition of a suspected case, it will need to
be classified using information from the investigation and
based on clinical, epidemiological and laboratory criteria.
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• Using standard case definition and
case classification ensures that every
case is defined and classified in the
same way.
• This standardization facilitates
confirmation of outbreaks as well as
aggregation, analysis and
interpretation of data, and
comparison between geographic
areas over time.
• Case definitions should be distributed
to health facilities at all levels.
Ref: WHO Measles Surveillance Standards
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Case classification definitions
Laboratory Confirmed Epidemiologically Linked
Measles Case Measles Case
A suspected case of measles that A clinical case of measles that has
has been confirmed positive by not been confirmed by a laboratory,
testing in a proficient laboratory, but was geographically and
and vaccine-associated illness temporally related, with dates of rash
has been ruled out. onset occurring 7-21 days apart from
a laboratory-confirmed case or
another epidemiologically linked
measles case.
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ORGANIZATION Action 10
Review PAGE 10 (Dec-21)
Case classification definitions
Clinically Compatible Discarded Case
Measles Case
A suspected measles case that has been
A clinical case of measles, but no investigated and discarded as non-
measles through:
adequate clinical specimen was
taken, and the case has not been • negative laboratory testing in a
linked epidemiologically to a proficient laboratory on an adequate
specimen collected during the
laboratory-confirmed or proper time after rash onset; or
epidemiologically-linked case of
• epidemiological linkage to a
measles or other communicable laboratory-confirmed outbreak of
disease. another communicable disease that
is not measles; or
• confirmation of another etiology; or
• failure to meet the clinically
Photo: CDC/Barbara RIce
compatible measles case definition
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The WHO Measles Outbreak Guide lists definitions for measles
public health surveillance
• Case definitions for case finding (e.g., suspected and Refer
to the
clinical) WHO
• Case classifications Measles
Outbreak
• Laboratory confirmed Guide
• Epidemiologically linked
• Clinically compatible
• Discarded
• Other definitions
• Acute measles deaths
• Suspected and laboratory confirmed measles outbreak
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A reminder on rubella
• Surveillance for rubella should be integrated with
measles case-based surveillance.
• Suspected measles outbreaks may be eventually
confirmed as rubella and some may be mixed
measles/rubella - in such cases guidelines for
rubella outbreaks should be followed.
• Rubella outbreaks also require congenital rubella
syndrome (CRS) surveillance.
• Infants with congenital rubella should be Child with CRS. Photo: CDC
considered infectious during the first year of life –

rubella outbreaks may need additional IPC around
cases.
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Epidemiological linkage
In measles elimination settings, epidemiologic
linkage is established when there is contact
between two people with a plausible mode of
transmission at a time when all the following In elimination
three criteria are met: settings, being a
known contact is
1)One person is likely to be infections (4 days criteria for
before to 4 days after rash onset); AND epidemiological
2)The other has a rash onset that starts 7-21 linkage.
days before or after this contact; AND
3)At least one person in the chain of
epidemiologically linked cases is laboratory
confirmed.
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Epidemiological linkage
• Highly endemic countries often

have limited resources to perform
comprehensive contact tracing.
• In this situation, an epidemiological
linkage can be defined as being in
the same geographical area (e.g.,
district, village or neighbourhood)
within 30 days of a laboratory-
confirmed case.
Photo: WHO/Tom
Pietrasik
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Laboratory confirmation
• Analysis of serum specimens for presence of measles-

or rubella-specific IgM antibodies is the most widely
used testing method for laboratory confirmation.
• Enzyme immunoassay (EIA) is recommended by the
WHO Global Measles and Rubella Laboratory Network
(GMRLN) for the detection of virus-specific IgM
antibodies in serum. Measles Virus
• For surveillance purposes, an adequate serum sample
for measles or rubella is one that is obtained within 28
days after the onset of rash.
• If the test result is negative and the specimen was
drawn within 3 days of rash onset, then a second
specimen should be collected and tested for anti-
measles IgM and IgG.
Rubella Virus
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Laboratory confirmation
• The use of dried blood spots (DBS) and oral fluid (OF)
are acceptable alternative samples when logistical
barriers exist for proper collection, processing and
transport of serum specimens.
• Collection and genomic analysis of representative
clinical measles and rubella specimens is critical to Dried blood spots
(Photo: CDC)
understand the genotype diversity of measles and
rubella in a given country. It provides evidence on the
elimination of endemic circulation.
• For more information on laboratory testing, specimen
collection and genotype analysis, see the WHO
Manual for laboratory-based surveillance of measles,
rubella and CRS. Oral Fluid Collection (Photo:
CDC)
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Key messages
• All signals, regardless of their source, serve to alert public health
authorities to possible suspected cases which need to be verified
and investigated to determine if they truly represent measles.
• Countries should have sensitive high-quality measles-rubella
surveillance systems, complemented by early warning and response
systems that can quickly identify signals.
• Epidemiological linkage is important for identifying contacts and
slowing spread of the disease through intervention.
• Prior to deployment, you must be familiar with the WHO and national
case definitions for measles and rubella.
• You will need to know the laboratory confirmation procedures in your
country.
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Reference documents
WHO Surveillance Standards for Measles
https://www.who.int/immunization/monitoring_surveillance/burden/vpd/WHO_SurveillanceVaccinePreventable_11_Measle
s_R2.pdf
WHO Surveillance Standards for Vaccine Preventable Diseases

https://apps.who.int/iris/bitstream/handle/10665/275754/9789241513920-eng.pdf?sequence=1&isAllowed=y
WHO guide on Early detection, assessment and response to acute public health events
https://apps.who.int/iris/bitstream/handle/10665/112667/WHO_HSE_GCR_LYO_2014.4_eng.pdf?sequence=1&isAllowed
=y
WHO Manual for laboratory-based surveillance of measles, rubella and CRS

https://www.who.int/publications/m/item/chapter-9-manual-for-the-laboratory-based-surveillance-of-measles-rubella-
and-congenital-rubella-syndrome
Measles outbreak guide
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Thank you.
World Health Organization

Geneva, Switzerland
WORLD
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Module 3: Detecting and

• National surveillance systems quickly detect and notify public

At the end of this module, you will be

• Signals are data or information that may

Refer to the WHO

• A signal detected through community-based

• There are two case definitions used for case finding –

considered infectious during the first year of life –

• Highly endemic countries often

• Analysis of serum specimens for presence of measles-

WHO Surveillance Standards for Vaccine Preventable Diseases

WHO Manual for laboratory-based surveillance of measles, rubella and CRS

Measles outbreak guide

World Health Organization

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