Measles outbreak investigation and public health reponse in Kasserine district. Tunisia, 2019

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Background:
Measles is a mandatory notifiable disease in Tunisia. In Kasserine district (Central west Tunisia), the annual incidence of measles is 1 to 2 cases per year and the overall vaccination coverage is 90%. A measles outbreak occurred on January 2019 in Kasserine. We describe the local outbreak investigation and public health response.

Methods:
An intensive door-to-door active search was carried out to identify measles cases. Any person with generalized maculopapular rash and fever was defined as suspected case. A suspected case with positive laboratory results was considered laboratory confirmed. Information on personal details, residence, time of onset and immunization status were obtained. Measles immunization catch-up campaign and mass vaccination campaigns targeting 6-11 months; health care professionals and contacts were initiated.

Results:
From January 2019 to May 2019, 1532 cases and 21 deaths were reported in Kasserine. The attack rate was 0.3%. The highest attack rate was among infants <1 year (4.2%). The median was 8 years old and the sex ratio was 1.05. The vaccination status was documented for 995 cases: 645 (54%) cases were not vaccinated against measles and 350 (27%) had at least one dose of measles vaccine before the outbreak. The measles immunization catch-up campaign involved 922 children. The 6-11 month vaccination campaign involved 6198 infants. In total, 1798 contacts and 57 health professionals were vaccinated. Mass health education campaign promoting measles vaccination was conducted in all health care facilities and through Facebook and local radio stations.

Conclusion:
This outbreak occurred due to a large number of none or incompletely vaccinated children. Investigation provided an opportunity to identify high-risk groups and weaknesses in the routine immunization. Strengthening of routine immunization, surveillance, and early response actions is strongly recommended.

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