Validation of measles & rubella elimination, challenges in Ecuador and Haiti

Carlos Castillo-SolórzanoKatri Kontio

Eleventh Annual MeetingThe Measles and Rubella Initiative

September 18-19, 2012

Presentation Outline

Issues in documentation and validation process

Virus importations from other regions

Sustained outbreaks - Ecuador

Maintaining elimination - Haiti

How to maintain the Regional measles/rubella elimination?

Last Endemic Measles, Rubella and CRS Cases

MEASLES:Venezuela / NOV 16, 2002

CRS:Brazil/ AGO 26, 2009

RUBELLAArgentina/ FEB, 2009

> 12 years without endemic MEASLES virus transmission

> 12 years without endemic MEASLES virus transmission

> 3 years without RUBELLA endemic virus transmission

> 3 years without RUBELLA endemic virus transmission

Source: Country reports to PAHO/WHO.

Impact of measles resurgence to the Region• In 2011 an eightfold increase over the previous annual

average of 156 cases between 2003 and 2010.

• Most common genotypes identified were D4 and B3

• 174 measles virus importations were detected in the Region in 2011

0

200

400

600

800

1000

1200

1400

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Regional rate

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Brazil Canada Mexico USA Venezuela Others Regional rate

Rate: 1.37 X 1,000,000 pop.

Co

nfi

rmed

Cas

es

N=119 N=108

N=1374

N=85

N=226

N=176 N=207

N=253

N=89

Distribution of Confirmed Measles Cases Followingthe Interruption of Endemic Transmission,

the Americas, 2003-2012*

Source: Country reports to PAHO/WHO.

* Data as of EW 36/2012.

N=129

The role of the laboratory in a context of low incidence

Pregnant women Post-vaccine False positives or cross-reaction False negatives: is it a problem in this stage of

elimination?

– These cases should be investigated on a case-by-case basis taking the epidemiological information into account

– A second blood sample

– Additional tests may be required

ALGORITHM FOR SPECIMENS : IgM positive and indeterminate results

IgG test

YESI

IgG Positive

There first serum sample available for further

investigation?

IgG Negative

Collect second blood specimen

Second serum sample collected

Resultados IgG de sueros pareados (primera y segunda muestra)

ResultsIgG, second sample

Avidity testing

IgG test

NO

Collect second serum sample

IgG NegativaIgG Positiva

Te case discarded

YESI

RT-PCR /VIRAS

isolation

Sequencing and genotyping

Positive

Respiratory or urine sample

exist?*

Indeterminate results (cannot be confirmed

nor discard))

Report as RT-PCR negative

Negative

IgG titers permanently

stable

IgG titers increased four times or more

IgG titers increased less than 4 times

DISCASRDED

CONFIRM RECENT

CONTACTS

Indeterminate results (revise

tiempo de recolección muestras)

IgG Negative

IgG Positive

CASE DISCARDE

D

CONFIRM RECENT

CONTACT

Low avidity

High avidity

Confirm contacts <3

months

Evidence of

contacts>3 meses

Report as RT-PCR positive with identified genotype

Efforts maintaining the elimination of endemic disease is more expensive than eliminating the disease

Health care-associated measles outbreak in the United States after an importation: challenges and economic impactAn infected Swiss traveler visited hospital A in Tucson, Arizona, and initiated a predominantly health care-associated measles outbreak involving 14 cases in 2008. The 2 hospitals spent US$799,136 responding to and containing 7 cases in these facilities. community partners. J Infect Dis. 2011 Jun 1;203(11):1517-25.

The Cost of Containing One Case of Measles: The Economic Impact on the Public Health Infrastructure—Iowa, 2004The containment costs of 1 measles case in this outbreak were high. The costs to the Iowa public health infrastructure of preventing the spread of disease from these cases were $140 000. Pediatrics 2005;116:1--4.

Containment costs for a measles outbreak in Indiana, USA - 2005

Costs item Unitary cost (USD)

Cost per patient 4,932

Wages and salaries 108,592

Overhead 30,431

MMR vaccine and immune globulin

21,692

Mileage 1,610

Other 5,360

TOTAL 167,685Source: Parker A, Staggs W, Dayan G et all. Implications of a 2005 measles outbreak in Indiana for sustained elimination of measles in the United States. The New England Journal of Medicine, Vol 355, No 5, August 3, 2006

Total number of cases was 34; the majority was among 5-19 years old and 32 lacked evidence of measles vaccination.

Estimated costs of containing measles outbreaks in selected LAC countries

Studies suggests that economic analyses may need to go beyond the costs of individual illness to account for the costs of protecting society, particularly when countries are close to elimination.

Country # of casesScope of outbreak control

activitiesCost

(USD)*

Chile (2009)

1 Limited to 1 municipality 12,400

Peru (2009) 11 municipality in Peru and 1

in Ecuador20,300

Ecuador(2011-2012)

266 Nationwide8.5

million

*Estimated costs include outbreak investigation, follow-up of contacts and vaccination activities Source: Country reports to FCH/IM

Last confirmed case EW 28/2012 (7/10/2012)

Source: Ministry of Health, Ecuador.Preliminary data by EW 36/2012

05

101520253035404550

24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 32 33 34 35 36 37

Nº ca

sos

Tungurahua Pichincha Guayas Cotopaxi ChimborazoPastaza Morona S Manabi Sto. Domingo

Semana Epidemiológica

Ecuador outbreakAll confirmed cases = 329 (EW 24/2011 to EW 37/2012)

Sustained outbreak with low incidenceFirst

cases were not notified on time

Measles attack rate by age group, Ecuador 2012*

Fuente: PAI, Ministerio de Salud Pública de Ecuador* Datos preliminares a la SE 12/2012

Attack rate per 100.000 population = 1,78

Fuente: Reporte de país a Septiembre 2008

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1965 1968 1971 1974 1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010

Año de nacimiento

% V

acci

nate

d

0

10

20

30

40

50

60

70

80

90

100

% V

acci

nate

d

Routine Program-ASA Routine Program MMR

Follow-up 1998 (1-4)-ASA-99% Follow-up 2002 (6m-14)-SR-99%

Follow up 2008 (1-6) SR-98% Follow up 2011

Age groups16-39 yearsBoth sexes: 98%Year: 2004

The results of the susceptible population cohorts calculated at the national level in many cases do not reflect the reality of the coverage in the provinces, due to heterogeneity in coverage

The results of the susceptible population cohorts calculated at the national level in many cases do not reflect the reality of the coverage in the provinces, due to heterogeneity in coverage

Recent measles outbreak suggest over-estimation of routine and SIAs coverage in Ecuador?

Cohort Analysis protected MR by year of birth and vaccination strategies. Ecuador 1965-2010

Introduction MMR in the routine program, 1999

Coverage range

<80%80-94%≥95%

Source: PAHO-WHO/UNICEF Joint Reporting Form, 2012.

Administrative coverage 2011:MMR1 = 94%MMR2 = 92%

Heterogeneity in coverageEcuador 2011

Characterization of the affected population

Other factorsOver crowded inpatient wards

High risk groups: unvaccinated persons (religious groups or other groups that reject vaccination) or in specific geographic areas, such as in indigenous communities, in large cities (especially on the peripheries), and in rural and border areas with limited access to health care.

Laboratory analysis of measles / rubella in serum samples of the dengue IgM-negative cases with presence of fever and rash in three stages during the outbreak:

1. Analysis before the detection of the first measles case to see previous circulation of measles virus

2. Analysis during the outbreak in provinces, which have not reported confirmed cases;

3. In order to provide evidence of not having measles virus circulation, collected specimens should be collected also within the last three months after detection of the last case.

Outbreak response: dengue analysis

Fuente: Base de Datos Guayas :MESSS-ISIS

Challenges

Communications between epidemiology and laboratory teams - the regular meeting of the EPI teams, surveillance and laboratory is recommended to conduct the analysis of the cases, especially the last cases reported

Private sector participation – involvement of the private clinics and the laboratories in detecting and notifying the suspected and confirmed cases

Haiti: Epidemiology of measles/rubella

Introduction of the MCV (≈ 1982) + campaigns Last epidemic situation in 2000 Last measles case: September 2001 Last rubella case: November 2006

2005 2006 2007 2008 2009 2010

# of suspected cases

4 68 24 6 3 19

Population 8621457 8866163 9117815 9376609 9642749 9916443

Rate 0.1623 0.7669 0.2635 0.0639 0.0311 0.1916

Reporting rate of suspected case Haiti 2005-2010

Source: MSPP Haiti

Quality of surveillance

Age group:1-19 yearsMen and Women** 94% CoverageYear: 2007-2008

Analysis of cohorts protected against measles and rubella bybirth year and vaccination strategy, Haiti 1980-2010

Status of the documentation/verification of measles, rubella and CRS elimination in Haiti

Components Status

Active case search for measles and rubella in hospitals and the community

Retrospective search of CRS

Measles/rubella: Confirmed cases by lab :0; Compatible cases: 0CRS: Detected CRS suspect cases: 273. Confirmed cases and Compatible cases: 0

Vaccinated Population Cohorts

Immunization campaign is accomplishedSeroprevalence study of measles and rubella: Test for measles/rubella IgG antibody in random sample of 740 sera is ongoing

Sustainability of Measles, Rubella, and CRS Elimination

The process of strengthen the routine immunization is ongoing including funding with involvement of all the partners

RMC Coverage 9m-9 yAdministrative Coverage 9m-9 y

RMC Coverage 1-4 yAdministrative Coverage 1-4 y

Immunization RR Coverage (9m-9 y) and (1-4 y)by Department, Haiti 03-08-12

Référence: SIVAC

< 80 %

80-94 %

95 a + %

Référence: MRC

NordNord Est

Centre

Ouest

Sud Est

Nord Ouest

Grand’Anse

Artibonite

Sud

Nippes

A. Metropol

Ouest

NordNord Est

Centre

Ouest

Sud Est

Nord Ouest

Grand’Anse

Artibonite

SudNippes

A. Metropol

Ouest

Nord Nord Est

Centre

Ouest

Sud Est

Nord Ouest

Grand’Anse

Artibonite

SudNippes

A. Metropol

Ouest

Nord Nord Est

Centre

Ouest

Sud Est

Nord Ouest

Grand’Anse

Artibonite

SudNippes

A. Metropol

Ouest

Haiti= 96.0 %Haiti= 100 %

Haiti= 95.0 %Haiti= 100 %

Maintain the achieved results: Development of plans with partners and Multi-annual plan for the

Expanded Program on Immunization 2011–2015Strategies implementation

Phase 1: Maintain and strengthen the achievements of AISE with short-term activities such as the introduction of new vaccines, increased immunization coverage and strengthening epidemiological surveillance

Phase 2: Focuses on improving and sustaining the performance of routine immunization program

Maintain high-quality, elimination-standard surveillance, including full compliance with indicators, and ensure timely and effective

outbreak response measures to any wild virus importation

Implement external rapid assessments of measles, rubella, and CRS surveillance systems to increase robustness and quality of case detection and reporting and strengthen registries of congenital anomalies;

Conduct active case searches and review the sensitivity of surveillance systems in epidemiologically silent areas;

Involve the private sector in disease surveillance with a special focus on inclusion of private laboratories in the Regional Measles and Rubella Laboratory Network;

Enhance collaboration between epidemiological and laboratory teams to improve measles and rubella surveillance and the final classification of suspected cases;

Improve molecular genotyping of the confirmed cases throughout outbreaks

Maintain high population immunization coverage against measles and rubella (>95%)

Implement rapid coverage monitoring to identify populations susceptible to measles and rubella, focusing particularly on localities of high-risk populations:

live in high-traffic border areas, live in densely populated areas such as urban fringe settlements, live in areas with low vaccination coverage or high vaccination dropout rates, live in areas not reporting suspected cases (epidemiologically silent), live in areas of

high population density that also receive a large influx of tourists and other visitors, especially workers related to the tourism industry (such as those related to airports, seaports, hotels and hospitality sector, tour guides) as well as those in low density or isolated areas (ecotourism destinations),

are geographically, culturally, or socioeconomically difficult to reach, and are engaged in commerce/trade (such as through fairs, markets) or live in highly industrialized areas;

Implement high-quality follow-up vaccination campaigns.

THANK YOU!

www.paho.org/immunization

– Plan of Action to maintain the Regional elimination of endemic measles and rubella was approved in the 28th Pan American Sanitary Conference

How to maintain the regional measles/rubellaelimination?

How to maintain the regional measles/rubellaelimination?

Improved access to IM

service delivery

Integrating immunization services with other health

services

Organizing the network of service providers

Improving access to immunization services

Organizing Immunization service

delivery

Identify the best ways to increase uptake and the

vaccination coverage

Regional Documentation and Verification Process

Status:Regional report with the plan of action was presented to the Governing Bodies of the Pan American Health Organization on progress made in the implementation of Resolution CSP27.R2 18th of September 2012

Conclusion:After careful analysis of the reports submitted by the National Commissions and Subregional Commission:

–It appears that the interruption of endemic measles and rubella virus transmission has been achieved–The Region of the Americas continues to be exposed to high risk of virus importations-the countries have reported weaknesses and failures in their national surveillance systems and routine immunization programs, which make them particularly vulnerable to the risk of reintroduction of viruses that can cause outbreaks.

* It does not include clinical cases reported.** Five cases have been notified in the island of Saint Martin (1 import and 4 import-related). Data as of EW 52

NUMBER OF IMPORTED MEASLES CASES BY COUNTRY 2011

Country ImportImport related Unknown Source of Infection

Argentina 1 2 02 cases: D4 ( exposure to French and/or German tourists); 1 case (travel history to Italy)

Brazil 9 24 9 D4 (unknown source; recent travel to US); D4 (France), D4, source unknown

Chile 3 3 0D4 (outbreak < 1 case) recent travel to NY and 1 case with a travel history to Thailand and Malaysia, genotype D9.

Canada* 27 4 772India (D8) and D4, France (D4), England (D9); D4 and D9 (unknown source)

Colombia 1 5 0 1 case with travel history to Brazil

Dominican Rep. 2 0 0

1 case with travel history to Italy D4 / 1 case among a French tourist, it was confirmed by epidemical link.

Ecuador 1 262 0 No travel history, B3 genotype identified

Guadalupe** 7 6 1 France

French Guiana 2 3 0 France

Martinique 2 0 1  

Mexico 3 0 0 France

Panama 4 0 0

France, Mexico with a travel history to London); Mexico with travel history to NYC and Niagara falls, date of rash-onset. D4

United States 111 89 23

Travel history to Israel and Polonia; genotype D4, strain MVs/Wroclaw.POL/28.09/ ; China, Dominican Republic, France, France/UK (D4), France/Italy/Spain/Germany, India, Indonesia, Italy, Kenya (B3), Nigeria, Pakistan, Philippines; Philippines/Vietnam/Singapore/Malaysia; Poland (D4), Romania, United Kingdom, D4(unknown source)

Total 174 398 805  

* It does not include clinical cases reported.** Five cases have been notified in the island of Saint Martin (1 import and 4 import-related). Data as of EW 52

Number of import/imported related measles cases per country, The Americas - 2012

MEASLES

Country Import Import related Unknown Source of InfectionArgentina 1 0 0 D4 ItalyBrazil 1 0 9 D4 Portugal,Spain

Canada 3 0 0D4 from India, Uganda, Pakistan B3, Pakistan

Colombia 1 0 0 MadridEcuador 0 69 0 B3

United States 23 24 4

The outbreaks >1 case 3 cases, Romania; 14 cases, Ethiopia (B3), 6 cases Ethiopia (B3); 4 cases , UK D4)

Total 29 93 13  

Reported MMR1 and MMR2 coverage Latin America, US and Canada, 2011

0

20

40

60

80

100

ARG BOL BRA CAN CHI COL COR CUB DOR ECU ELS GTM HAI HND MEX NIC PAN PAR PER URU USA VEN

Co

ve

rag

e (

%)

MMR1 MMR2* Haiti coverage for MR vaccine in children<1 year of age

Source: Country reports through the PAHO-WHO/UNICEF Joint Reporting Form (JRF), 2012

95%

Background of the Ecuadorian measles outbreak

• In EW 24, 2011, the surveillance system caught in the parish Latacunga Canton Latacunga, Cotopaxi province, a suspected case of 2-year-old, who was later confirmed with genotype D4. No source of infection identified.

• In EW 28-29 two cases from the parish Atahualpa, Canton Ambato, Tungurahua province were identified (11 months and 2 years old), confirmed with genotype B3. No source of infection identified

• 327 confirmed measles cases (263 in 2011 and 69 in 2012) have been reported (EW28/2011 to EW37/2012)

• In EW 24, 2011, the surveillance system caught in the parish Latacunga Canton Latacunga, Cotopaxi province, a suspected case of 2-year-old, who was later confirmed with genotype D4. No source of infection identified.

• In EW 28-29 two cases from the parish Atahualpa, Canton Ambato, Tungurahua province were identified (11 months and 2 years old), confirmed with genotype B3. No source of infection identified

• 327 confirmed measles cases (263 in 2011 and 69 in 2012) have been reported (EW28/2011 to EW37/2012)

Cotopaxi EW 24: 1 caso EW 41-51 (7 casos)EW 3-26/2012 (4 casos)

Cotopaxi EW 24: 1 caso EW 41-51 (7 casos)EW 3-26/2012 (4 casos)

1

W TungurahuaE 28-48 (163 casos)EW 3/2012 (1 caso)

W TungurahuaE 28-48 (163 casos)EW 3/2012 (1 caso)

2

Pichincha EW 30-51 (34 casos)EW 3-9/2012 (14 casos)

Pichincha EW 30-51 (34 casos)EW 3-9/2012 (14 casos)

3

Guayas EW 40-52 (23 casos)EW 1-3/2012 (14 casos)

Guayas EW 40-52 (23 casos)EW 1-3/2012 (14 casos)

4

Chimborazo EW 46-46 (4 casos)

Chimborazo EW 46-46 (4 casos)

5

Fuente: PAI, Ministerio de Salud Pública de Ecuador. * Datos a la SE 30/2012

Evolution of the outbreak: Confirmed cases of measles by EW and province, Ecuador 2011-2012 *

Pastaza EW 46-52 (25 casos)EW 2-8/2012 (5 casos)

Pastaza EW 46-52 (25 casos)EW 2-8/2012 (5 casos)

6

Morona Santiago E W 2-24/2012 (28 casos)

Morona Santiago E W 2-24/2012 (28 casos)

7

ManabÍ EW 11/2012 (1 caso)

ManabÍ EW 11/2012 (1 caso)

9

Santo Domingo EW 49/2011 (1 caso)EW 12-13/2012 (3 casos)

Santo Domingo EW 49/2011 (1 caso)EW 12-13/2012 (3 casos)

8

Confirmed cases: age groups and attack rates 2011-2012

Age Year 2011 Year 2012 Total Attack rate 2011* Attack rate 2012*

<6 months 31 16 47 15.39 10

6 a 11 months 43 18 61 20 8.46

1 a 4 years 83 14 97 6.74 0.91

5 a 9 years 34 2 36 1.57 0.07

10 a 14 years 44 2 46 2.4 0.13

15 a 19 years 7 7 14 0.63 0.21

20 a 39 years 13 10 23 0.22 0.11

>40 years 5 0 5 0.12 0

Total 260 69 329

* Per 100,000 populations Source: Ministry of Health, Ecuador

Outbreak response

Enhanced surveillance in public and private sector Active search of suspected cases in institutions and in

communities Investigation of suspected cases (contact tracing and

monitoring) Community interventions (sampling, MRC, active case

search, vaccination ) Adaptation of health services (triage, isolation rooms) National vaccination campaign (6 months to 14 years

olds) RCM Vaccinations at night and in early mornings in specific

areas

Enhanced surveillance in public and private sector Active search of suspected cases in institutions and in

communities Investigation of suspected cases (contact tracing and

monitoring) Community interventions (sampling, MRC, active case

search, vaccination ) Adaptation of health services (triage, isolation rooms) National vaccination campaign (6 months to 14 years

olds) RCM Vaccinations at night and in early mornings in specific

areas

Implemented activities in Haiti

COMPONENT Sero-prevelance survey National MR: intensified

vaccination project; Independent coverage survey

Active case search for measles and rubella in hospitals

Active case search measles and rubella at the community level

Retrospective search of CRS (specialized institutions)

STATUS Serum specimens collected for

2012 antenatal clinic (ANC) sentinel survey for HIV, syphilis

RCM: coverage >95% Initial results from the survey?M&R: Investigated cases : 113 Confirmed cases by lab :0;

Compatible cases : 0CRS: Detected CRS suspect cases :

273 Investigated cases : 113 Investigated cases (<1 year old)

with blood specimen : 12 Confirmed cases by lab :0 Compatible cases : 0

Référence: SIVAC- DEPT

Immunization Administrative RR Coverage by Department,

9-11m, 1-4 y and 5-9 y, Haiti 03-08-2012

pour

cent

age

Départements

100 100100 100 100 100 100100 100100 100 100 100 100 100 100100 100100 100

100100100100 100 100

100 100

RR (9-11 m ) = 100. %Haiti RR (1-4 a ) = 100 %

RR (5-9 a ) = 100 %

100

Haiti: SustainabilityThe intensification activities are planned in a way that build upon what already exists and with the aim of leaving a routine vaccination program strengthened:

• Political commitment: Visibility of the routine program, and the coordination between national and international partners• Micro-planning: Staff trained in micro-planning, planning tools, areas of responsibility, well-defined target population, maps available• Training: pool of trained people, training of trainers, training materials .

Haiti: Sustainability• Information System: Pool of trained data managers, experience in using software, promoting the data organization, flow, analysis and quality• Supervision: Supervision plan for the regular program, pool supervisors trained and with experience on on-site training• Logistics: Distribution system, new equipment installed, pool of trained technicians, more efficient distribution and better wastage management• Epidemiological surveillance: Strengthening the national epidemiological surveillance, pool of field epidemiologists, an expanded network of reporting sites, national laboratories capable of testing for multiple diseases, RMC.

Maintain the role of the laboratory in a context of low

incidenceOccurrence of sporadic positive IgM:  False positive or true positive?  The correct classification of the case depends on the review of laboratory results and clinical and epidemiological data (last vaccination, contact with international visitors, travel history within 21 or 23 days of rash onset).

Probability of false negative IgM results:First blood sample collected <= 3 days of rash onset Strongly suspected measles or rubella: recent travel, exposure and vaccination history.

Additional tests may be required: Viral detection (RT-PCR) or viral isolation Second blood sample (IgM, IgG) Avidity Test Differential Diagnosis: (dengue, Parvo B19, HHV-6, ...)

MVs/Barranquilla.COL/37.11/1 2011725332 MVs/Barranquilla.COL/37.11/2 2011725335 MVs/Barranquilla.COL/38.11 2011725337

MVs/Cotopaxi.ECU/26.11 2012721966 MVs/Barranquilla.COL/35.11 2011725331 MVs/Barranquilla.COL/33.11 2011725279 MVs/Barranquilla.COL/34.11 2011725281

Measles Sequences from Ecuador and Columbia, Measles Sequences from Ecuador and Columbia, 2011. Genotype D4 Sequences2011. Genotype D4 Sequences

“Manchester Lineage” from Europe

MVs/Ambato.ECU/38.11/2 2011725344 MVs/Pichincha.Ecuador/43.12/1 2012721961 MVs/Ambato.ECU/36.11 2011725341 MVs/Pichincha.Ecuador/43.12/4 2012721960 MVs/Tungurahua.ECU/42.11/2 2012721918 MVs/Ambato.ECU/38.11/1 2011725343 MVs/Ambato.ECU/29.11 2011725283 MVs/Tungurahua.Ecuador/40.11 20212721967 MVs/Guayas.Ecuador/49.12 2012731964

MVs/Pichincha.Ecuador/45.12/1 2012721962 MVs/Pichincha.Ecuador/43.12/2 2012721958

MVs/Guayas.Ecuador/45.12/2 2012721963 MVs/Tungurahua.ECU/39.11/4 2012721908 MVs/Ambato.ECU/30.11 2011725285 MVs/Tungurahua.ECU/42.11/1 2012721916 MVs/Tungurahua.ECU/39.11/2 2012721906 MVs/Tungurahua.Ecuador/40.12/1 201272... MVs/Tungurahua.ECU/39.11/5 2012721909 MVs/Guayas.ECU/45.11 2012721917 MVs/Pichincha.Ecuador/43.12/3 2012721959 MVs/Tungurahua.Ecuador/41.12/2 201272... MVs/Tungurahua.Ecuador/40.12/2 201272... MVs/Tungurahua.ECU/39.11/3 2012721907 MVs/Tungurahua.Ecuador/39.12 2012721951 MVs/Latacunga.ECU/45.11 2012721920 MVs/Tungurahua.Ecuador/43.12 2012721957 MVs/Tungurahua.Ecuador/41.12/3 201272... MVs/Pichincha.ECU/45.11 2012721912 MVs/Tungurahua.ECU/39.11/1 2012721904 MVs/Tungurahua.ECU/45.11 2012721914 MVs/Guayas.Ecuador/45.11 2012721965

5

Measles Sequences from Measles Sequences from Ecuador and Columbia, Ecuador and Columbia, 2011. Genotype B3 2011. Genotype B3 SequencesSequences