8 th Global Measles and Rubella LabNet Meeting, Sept 2010 Key Recommendations GLOBAL MEASLES AND...

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


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


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


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

Data Reporting Data Reporting

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

Sequencing data reporting Sequencing data reporting

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


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


Higher resolution sequencingHigher resolution sequencing

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

2020 20

Quality AssuranceQuality Assurance

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


New Procedures New Procedures

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


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


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

FundingFunding

$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


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

Thank you to all our LabNet Supporters Thank you to all our LabNet Supporters


CDC

WHO

Korean CDC

National MsOH

IFFIM

Luxemburg Gov't

Merck

Measles Initiative

HPA

Labs belonging to LabNet

30

Programmes sharing

resources

Polio

JE

YF

8 th Global Measles and Rubella LabNet Meeting, Sept 2010 Key Recommendations GLOBAL MEASLES AND...

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