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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 3  |  Page : 111-115

Surveillance of measles disease in Libya, 2018


Department of Public Health, Faculty of Public Health and Nursing, Al Asmarya Islamic University, Zliten, Libya

Date of Submission21-Apr-2021
Date of Acceptance26-Aug-2021
Date of Web Publication11-Oct-2021

Correspondence Address:
Dr. Salem Alkoshi
Department of Public Health, Faculty of Public Health and Nursing, Al Asmarya Islamic University, Zliten
Libya
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ljms.ljms_24_21

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  Abstract 


Background: Measles surveillance program plays an essential role in determining disease prevalence data and outbreaks as well as monitoring the preventive activities toward measles elimination. This study illustrates epidemiological measles indicators through the national measles surveillance program in Libya in the year 2018. Materials and Methods: Annual measles surveillance report in 2018 was analyzed to figure out the spread of measles disease. Case-based surveillance is being implemented to notify suspected measles cases (skin rash and fever) through the measles surveillance system. The program depends on immediate notification of suspected measles cases and blood sample collection by official measles surveillance officers covered most health facilities in the country. National measles laboratory is the only official institute authorized to confirm measles cases. The characteristics such as the number of confirmed measles cases, deaths, age group, measles trends, and vaccination status were analyzed to find the indicators, as well as the incidence rate of measles cases was calculated nationwide. Results: Total number of measles cases was 1059 confirmed from 1852 suspected measles cases. Of confirmed cases, 339 were laboratory confirmation and 720 were epi-linked, with limited deaths (2 cases) were registered in the year. Seven outbreaks were detected in several locations. The age group of most cases (86%) was below 3 years of age group. Measles incidence was 152 per million which higher than previous years and comparable to many neighboring countries. The measles vaccine was not reached to 47% of suspected cases. Seasonality of measles was not in normal trend as it was continued high even in the summer month. Conclusion: A significant measles burden was shown through the measles surveillance system even though high measles vaccination coverage rate was officially documented. Supplementary immunization activities should be an essential action point to mitigate measles morbidity.

Keywords: Elimination, incidence, Libya, measles, surveillance


How to cite this article:
Alkoshi S. Surveillance of measles disease in Libya, 2018. Libyan J Med Sci 2021;5:111-5

How to cite this URL:
Alkoshi S. Surveillance of measles disease in Libya, 2018. Libyan J Med Sci [serial online] 2021 [cited 2021 Dec 5];5:111-5. Available from: https://www.ljmsonline.com/text.asp?2021/5/3/111/328084




  Introduction Top


Measles disease is a highly contagious disease, infecting around 90% of unvaccinated people who exposed to measles. It is a respiratory disease caused by a virus transmitted through the air by coughs or sneezes.[1],[2],[3] The disease is a leading cause of infant mortality despite the measles vaccine has been administrated since 1963.[2],[4],[5],[6] In 2017, global measles mortality was 110 thousand which were mostly among children aged below 5 years.[3],[5],[7] In the first 4 months of 2019, measles cases were extremely increased by 300% compared with the same period of 2018. From January to April 2019, 112 thousand cases were reported from 170 countries compared to 28 thousand from 163 countries at the same period in 2018.[7],[8] In Europe, the burden of measles was 82,500 in 2018, three more than measles cases in 2017 and 15 times more than in 2016.[7],[9] In the US, measles cases were 555 reported in the first 4 months of 2019 which was second highest number since measles was officially eliminated in 2000.[8]

The low coverage rate of measles vaccination is the main cause of the outbreak.[3],[7] Measles is almost entirely preventable by giving two doses of measles-containing vaccine (MCV) being safe, effective, and inexpensive. The vaccine saved more than 21 million lives (80%) from 2000 to 2017. The major reasons for not being vaccinated are varying significantly between communities being limited access to efficient vaccination services, misinformation about vaccines, conflict, and displacement, or low awareness about vaccine benefits.[3],[5],[7],[10] MCV is very effective to 97% of children if giving two doses, while one dose is about 93% effective.[6],[11] Vaccine-induced measles immunity is lifelong in most people.[11] In Libya, National Center for Disease Control (NCDC) is responsible for implementing measles surveillance program in the country. This study presents epidemiological measles indicators through national measles surveillance program in Libya in the year 2018.


  Materials and Methods Top


The study aims to determine the epidemiological indicators of measles disease in the country of Libya in 2018. Retrospective measles surveillance data were analyzed to find the characterization of measles disease. The measles surveillance system is based on an immediate notification of any suspected measles case defining as any case with skin rash and fever at any age.[12],[13]

The program depends on a network of trained public health officers at health facilities in most districts in the country to notify suspected measles cases. A blood sample should be taken from suspected patients for measles laboratory confirmation by national measles laboratory approved by the World Health Organization (WHO).[14] The national measles laboratory is the only responsible to test suspected measles samples in the country.

According to surveillance standard operating procedures for communicable disease surveillance and response (SOPs), measles outbreak is evidenced if 3 or more laboratory-confirmed cases with epidemiologically linked.[13] The NCDC has the authorization to declare an outbreak if the evidence of the outbreaks is set. The incidence per million is calculated for each district and for nationwide using the census of 2018.[15]

Data analysis

The study analyzed measles surveillance data in 2018 to describe the epidemiology of measles cases for each district, the demographic data, trends on months, incidence per/million population, vaccination status of suspected cases, and genotype of virus. The incidence of cases was calculated based on the population of 2018.[16] Furthermore, a comparison of incidence/million with the previous year will be showed.

Ethics

Consent was obtained from the management of the measles surveillance program to use measles data in 2018 and previous years (2005–2017).


  Results Top


Number and incidence of measles cases

A total of measles cases were 1059 in the whole year 2018, confirmed from 1852 suspected measles notification, of measles cases, 339 laboratory confirmations and 720 epi-linked. The highest numbers of measles cases were showed in Zliten city (499) and Benghazi (374). Measles deaths were 2 cases in Algatroun and Zliten. The genotype was B3 detected in 4 cities. The incidence rate was 152 per million population, which is the highest measles incidence count in the past 8 years [Figure 1]. The highest incidence was found in Zliten city (1793 per million). [Table 1] shows the number of measles cases, deaths, and incidence per million in each infected city in the country.
Figure 1: Incidence of measles cases per million during the period 2010–2018

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Table 1: Measles cases and genotype detection at the infected districts

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Age group of measles cases

The highest number of measles cases 380 (36%) was among children aged below 1 year, and 301 (28%) measles cases were in the age group from 1 year to below 3 years. The distribution of measles cases by age group can be shown in [Figure 2].
Figure 2: Age group of measles cases

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Monthly trends

Measles cases started in March (1 measles case) and increased steadily to May (14 measles cases); then, the disease increased reaching the peak in July and August, 208 cases and 204 cases, respectively. The disease started to decrease slightly in September (153) and November (140) and reached 119 cases in December. The trends of measles cases can be shown in [Figure 3].
Figure 3: Trends of measles disease on months

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Vaccination status of suspected measles cases

Vaccination status was shown at all suspected measles cases. The unvaccinated cases were 868 (47%), while the cases with one dose were 120 (7%), and two doses were 564 (30%). Otherwise, no data related to vaccination status in 300 (16%) cases. [Figure 4] shows the vaccination status of suspected cases.
Figure 4: Trends of confirmed measles disease on months

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  Discussion Top


The measles elimination program is one of the important preventive programs globally to reduce the incidence of measles cases (below 5 cases per million). The program depends on active case-based measles surveillance and high immunity level among the population. The efficient immunity can be built by routine measles vaccination (90% coverage rate) and mass measles immunization campaigns (95% coverage rate).[10],[17],[18] The aim of this study is to present the burden of measles disease in Libya in the year 2018 using retrospective national measles surveillance data. Libya strives to accomplish the ultimate goal of measles elimination by implementing global measles strategic plan.[13] There is an improvement in conducting measles surveillance program in Libya as the number of suspected measles cases notified through the measles surveillance system reaches 1852 compared to 220 in 2017 and 48 in 2016.[12],[19] The improvement was attributed to a plan for strengthening the program such as training organized by NCDC and WHO Libya office. The number of measles cases was 1059; of those, 339 were laboratory confirmation and 720 were epi-linked, while measles deaths were two cases. The incidence rate was 152 per million being significantly increased compared to 8 years ago shown in [Figure 1]. Libya was one of the EMRO countries with high measles incidence.[20] Comparing to the global situation in the period between August 2018 and July 2019, Libya was in the mid-level incidence rate since many countries were higher such as Madagascar (6,067/million), Ukraine (1,844/million), Georgia (1,226/million), and Kazakhstan (557/million).[21] However, many countries had lower measles burden than Libya for instance Brazil (56/million), Iraq (34/million), Tunis (1/million), and UAE (18/million). Measles incidence in Libya was comparable to some EMRO countries such as Pakistan (156/million) and Lebanon (164/million).[20] Libya faced seven outbreaks at different areas during 2018 located in various locations, east, west, south, and north which met the definition of measles outbreak (at least three laboratory-confirmed cases epidemiologically linked) according to SOPs and WHO criteria.[13],[22] There was no new genotype detected, in which measles genotype circulating was B3 being similar to the reference strain.[23]

Due to several outbreaks in Libya during 2018, the trends of measles remained high particularly in summer being not the usual seasonality of measles.[22] Measles trends were unlike with EMRO countries and the US; otherwise, Sudan had similar monthly trends as in Libya.[20],[24]

Even though a significant burden of measles disease was shown, the official coverage rates of measles vaccine doses in MCV1 and MCV2 were high in the same year, 97% and 96%, respectively.[25] However, 47% of suspected measles cases were unvaccinated according to this study, while 30% received two doses [Figure 4]. Most cases (64%) were found at age group below 3 years which was nearly similar to the global age distribution of measles cases.[21] The potential cause of the spread of measles could be attributed to the immunity gaps.[22] Global strategy to eliminate measles requires achieving and maintaining high immunity in the community. Measles vaccination coverage rate must reach more than 90% with each of the two doses of MCV to accomplish the elimination. In case of unable to achieve a high coverage rate of vaccination through routine vaccination, supplementary immunization activities (SIAs) must be implemented.[18],[26] In addition, active measles surveillance system is essential to determine measles indicators, outbreaks and assess preventive programs as well as set priorities to create plans, resources, and respond to outbreaks.[18] Measles surveillance system plays a crucial role to assess that measles elimination is accomplished or needs more support.


  Conclusion Top


The measles surveillance system is an essential program to determine measles indicators and alert outbreaks. The system is monitoring the effectiveness of preventive programs such as vaccination. A substantial strategy to eliminate measles disease is being adopted by the WHO worldwide including Libya. The measles surveillance system in Libya had been significantly improved in strengthening the program to find measles burden and outbreaks. The massive measles burden highlights gaps in immunization activities whether low coverage rate or shortage vaccine-induced immunity. This situation is justified to boost immunity by an urgent response to the community such as measles immunization campaign nationwide.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
CDC. Measles Data and Statistics; 2019. Available from: https://www.cdc.gov/measles/downloads/MeaslesDataAndStatsSlideSet.pdf. [Last accessed on 2019 Sep 08].  Back to cited text no. 1
    
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Maine. Measles. Division of Disease Surveillance. Maine Center for Disease Control and Prevention; 2019. Available from: https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/vaccine/measles.shtml. [Last accessed on 2019 Sep 08].  Back to cited text no. 2
    
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CDC. Global Measles Outbreaks; 2019. Available from: https://www.cdc.gov/globalhealth/measles/globalmeaslesoutbreaks.htm. [Last accessed on 2019 Sep 09].  Back to cited text no. 3
    
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CDC. Measles, Mumps, and Rubella (MMR) Vaccine Safety; 2019. Available from: https://www.cdc.gov/vaccinesafety/vaccines/mmr-vaccine.html. [Last accessed on 2019 Sep 08].  Back to cited text no. 4
    
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WHO. New Measles Surveillance Data from WHO. Immunization, Vaccines and Biologicals 2019. Available from: https://www.who.int/immunization/newsroom/measles-data-2019/en/. [Last accessed on 2019 Sep 09].  Back to cited text no. 7
    
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Mahase E. Measles cases rise 300% globally in first few months of 2019. BMJ 2019;365:l1810.  Back to cited text no. 8
    
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WHO. Measles in Europe: Record Number of Both Sick and Immunized; 2019. Available from: http://www.euro.who.int/en/media-centre/sections/press-releases/2019/measles-in-europe-record-number-of-both-sick-and-immunized. [Last accessed on 2019 Sep 09].  Back to cited text no. 9
    
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WHO. Measles; 2018. Available from: https://www.who.int/immunization/diseases/measles/en/. [Last accessed on 2019 Sep 08].  Back to cited text no. 10
    
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CDC. MMR and MMRV Vaccine Composition and Dosage; 2019. Available from: https://www.cdc.gov/vaccines/vpd/mmr/hcp/about.html. [Last accessed on 2019 Sep 08].  Back to cited text no. 11
    
12.
NCDC. Annual Measles Report. National Measles Elimination Program, Surveillance and Rapid Response Administration. Libya: National Center for Disease Control (NCDC); 2018.  Back to cited text no. 12
    
13.
NCDC. Surveillance Standard Operating Procedures for Communicable Disease Surveillance and Response (SOPs). National Measles Elimination Program, Surveillance and Rapid Response Administration. Libya: National Center for Disease Control (NCDC); 2017.  Back to cited text no. 13
    
14.
WHO. Measles and Rubella Laboratory Network. Measles 2012. Available from: https://www.who.int/immunization/diseases/measles/global_coordination/en/index6.htm. [Last accessed on 2019 Sep 09].  Back to cited text no. 14
    
15.
General Information Authority (GIA), Population Survey. National Corporation for Information and Documentation in Libya; 2006. https://gia.gov.ly/ar [Last accessed on 2019 Sep 09].  Back to cited text no. 15
    
16.
Bank, W. World Development Indicators. Libya 2019. Available from: https://databank.worldbank.org/reports.aspx?source=2 and country=LBY. [Last accessed on 2019 Sep 09].  Back to cited text no. 16
    
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WHO. Measles Elimination Field Guide. Netherlands: WHO Library Cataloguing-in-Publication Data; 2013.  Back to cited text no. 17
    
18.
WHO. Global Measles and Rubella Strategic Plan: 2012-2020. Netherlands: WHO Library Cataloguing-in-Publication Data; 2012.  Back to cited text no. 18
    
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NCDC, Annual Measles Report. National Measles Elimination Program, Surveillance and Rapid Response Administration. Libya: National Center for Disease Control (NCDC); 2017.  Back to cited text no. 19
    
20.
EMRO, Measles and rubella surveillance summary and data analysis of selected performance indicators. 2018. EMR, Week 52 2018. http://www.emro.who.int/images/stories/vpi/documents/measles-rubella-2018-emr.pdf [Last accessed on 2019 Sep 23].  Back to cited text no. 20
    
21.
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22.
WHO. Guidelines for Measles and Rubella Outbreak Investigation and Response in the WHO European Region. Netherlands: WHO Regional Office for Europe; 2013.  Back to cited text no. 22
    
23.
Rota PA, Brown K, Mankertz A, Santibanez S, Shulga S, Muller CP, et al. Global distribution of measles genotypes and measles molecular epidemiology. J Infect Dis 2011;204 Suppl 1:S514-23.  Back to cited text no. 23
    
24.
CDC. Measles Cases and Outbreaks; 2019. Available from: https://www.cdc.gov/measles/cases-outbreaks.html. [Last accessed on 2019 Sep 24].  Back to cited text no. 24
    
25.
WHO. WHO Vaccine-Preventable Diseases: Monitoring System. 2019 Global Summary; 2019. Available from: http://apps.who.int/immunization_monitoring/globalsummary/countries?countrycriteria%5Bcountry%5D%5B%5D=LBY. [Last accessed on 2019 Sep 24].  Back to cited text no. 25
    
26.
Orenstein W, Hinman A, Nkowane B, Olive JM, Reingold AL. Measles and rubella global strategic plan 2012–2020 midterm review. Vaccine 2018;36:A1-34.  Back to cited text no. 26
    


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