Validation of measles & rubella elimination, challenges in Ecuador

Report
Validation of measles & rubella elimination,
challenges in Ecuador and Haiti
Carlos Castillo-Solórzano
Katri Kontio
Eleventh Annual Meeting
The 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
> 12 years without endemic
MEASLES virus transmission
CRS:
Brazil/ AGO 26, 2009
> 3 years without RUBELLA
endemic virus transmission
RUBELLA
Argentina/ FEB, 2009
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
Distribution of Confirmed Measles Cases Following
the Interruption of Endemic Transmission,
the Americas, 2003-2012*
Rate: 1.37 X 1,000,000 pop.
Confirmed Cases
1400
1.6
N=1374
1200
1.4
1000
1.2
1
800
0.8
600
400
N=226
N=119
N=108
N=253
N=176
N=85
0.6
N=207
N=129
N=89
200
0.4
0.2
0
0
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Regional rate
Brazil
Canada
Mexico
USA
Venezuela
* Data as of EW 36/2012.
Source: Country reports to PAHO/WHO.
Others
Regional rate
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 caseby-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
There first serum sample
available for further
investigation?
YESI
NO
Respiratory or
urine sample
exist?*
Collect second
serum sample
IgG test
IgG test
YESI
IgG
Negative
IgG Positive
IgG Positiva
Second serum sample
collected
Collect second
blood specimen
Results
IgG, second sample
Resultados IgG de sueros
pareados (primera y
segunda muestra)
IgG Negativa
Te case
discarded
Indeterminate results
(cannot be confirmed
nor discard))
Avidity
testing
IgG
Negative
IgG
Positive
CASE
DISCARDE
D
CONFIRM
RECENT
CONTACT
IgG titers
permanently
stable
IgG titers
increased four
times or more
IgG titers
increased less
than 4 times
DISCASRD
ED
CONFIRM
RECENT
CONTACTS
Indeterminate
results (revise
tiempo de
recolección
muestras)
Low
avidity
Confirm
contacts <3
months
RT-PCR
/VIRAS
isolation
High
avidity
Evidence
of
contacts>
3 meses
Positive
Negative
Sequencing and
genotyping
Report as RT-PCR
negative
Report as RTPCR 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
impact
An 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,
2004
The 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
Total number of cases
was 34; the majority was
among 5-19 years old
and 32 lacked evidence
of measles vaccination.
Cost per patient
Unitary
cost (USD)
4,932
Wages and salaries
108,592
Overhead
30,431
MMR vaccine and
immune globulin
21,692
Mileage
1,610
Other
5,360
TOTAL
167,685
Source: 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
Estimated costs of containing measles outbreaks
in selected LAC countries
Country
# of cases
Scope of outbreak control
activities
Cost
(USD)*
Chile (2009)
1
Limited to 1 municipality
12,400
Peru (2009)
1
1 municipality in Peru and 1
in Ecuador
20,300
Ecuador
(2011-2012)
266
Nationwide
8.5
million
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.
*Estimated costs include outbreak investigation, follow-up of contacts and vaccination activities
Source: Country reports to FCH/IM
Ecuador outbreak
50
45
40
35
30
25
20
15
10
5
0
Last confirmed case EW 28/2012 (7/10/2012)
First
cases
were not
notified
on time
Sustained outbreak with low incidence
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 casos
All confirmed cases = 329 (EW 24/2011 to EW 37/2012)
Semana Epidemiológica
Tungurahua
Pastaza
Pichincha
Morona S
Guayas
Manabi
Cotopaxi
Sto. Domingo
Chimborazo
Source: Ministry of Health, Ecuador.
Preliminary data by EW 36/2012
Measles attack rate by age group, Ecuador 2012*
Attack rate per 100.000
population = 1,78
30
27.7
Tasa de ataque
25
23.8
20
15
10
7.7
5
1.6
2.4
0.9
0.2
0.09
0
<6 meses
6-11
meses
1-4 años 5-9 años
10-14
años
15-19
años
Fuente: PAI, Ministerio de Salud Pública de Ecuador
* Datos preliminares a la SE 12/2012
20-39
años
>40 años
Recent measles outbreak suggest over-estimation
of routine and SIAs coverage in Ecuador?
100%
100
90%
90
80%
80
70%
70
60%
50%
40%
30%
Age groups
16-39 years
Both sexes: 98%
Year: 2004
60
50
40
30
20%
20
10%
10
% Vaccinated
% Vaccinated
Cohort Analysis protected MR by year of birth and vaccination
strategies. Ecuador 1965-2010
Introduction MMR
in the routine
program, 1999
0%
0
1965 1968 1971 1974 1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010
Routine Program-ASA
Año de nacimiento
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
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
Fuente: Reporte de país a Septiembre 2008
Heterogeneity in coverage
Ecuador 2011
Administrative coverage 2011:
MMR1 = 94%
MMR2 = 92%
Coverage range
<80%
80-94%
≥95%
Source: PAHO-WHO/UNICEF Joint Reporting Form, 2012.
Characterization of the affected population
Affected
population
Affected
areas
• 90% of the affected population is indigenous
• Groups with high mobility (staff time, customs)
• Rural zones
• Areas inhabited by indigenous people who have migrated to the city
• Street vendors and food vendors in markets
• Overcrowding
Social
conditions • Access to culturally sensitive health services is limited
Over crowded inpatient wards
Other factors
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.
Outbreak response: dengue analysis
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.
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
Fuente: Base de Datos Guayas :MESSS-ISIS
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
Quality of surveillance
Reporting rate of suspected case Haiti 2005-2010
2005
2006
2007
2008
2009
2010
# of
suspected
cases
4
68
24
6
3
19
Population
8621457
8866163
9117815
9376609
9642749
9916443
0.1623
0.7669
0.2635
0.0639
0.0311
0.1916
Rate
Source: MSPP Haiti
Analysis of cohorts protected against measles and rubella by
birth year and vaccination strategy, Haiti 1980-2010
Age group:
1-19 years
Men and Women**
94% Coverage
Year: 2007-2008
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: 0
CRS: Detected CRS suspect cases:
273. Confirmed cases and
Compatible cases: 0
 Vaccinated Population
Cohorts
Immunization campaign is
accomplished
Seroprevalence study of measles
and rubella: Test for measles/rubella
IgG antibody in random sample of
740 sera is ongoing
 Sustainability of Measles,
The process of strengthen the
Rubella, and CRS Elimination routine immunization is ongoing
including funding with involvement
of all the partners
Immunization RR Coverage (9m-9 y) and (1-4 y)
by Department, Haiti 03-08-12
< 80 %
80-94 %
95 a + %
Administrative Coverage 9m-9 y
Haiti= 100 %
RMC Coverage 9m-9 y
Haiti= 96.0 %
Nord Ouest
Nord Ouest
Nord
Nord
Nord Est
Nord Est
Artibonite
Artibonite
Centre
Centre
A. Metropol
Grand’Anse
A. Metropol
Ouest
Ouest
Nippes
Grand’Anse
Sud Est
Sud
Nippes
Sud Est
Sud
Administrative Coverage 1-4 y
Haiti= 100 %
Ouest
Ouest
RMC Coverage 1-4 y
Haiti= 95.0 %
Nord Ouest
Nord Ouest
Nord
Nord
Nord Est
Artibonite
Artibonite
Centre
Centre
A. Metropol
Grand’Anse
Sud
Référence: SIVAC
Nippes
A. Metropol
Ouest
Ouest
Nord Est
Grand’Anse
Sud Est
Sud
Référence: MRC
Nippes
Ouest
Ouest
Sud Est
Maintain the achieved results:
Development of plans with partners and Multi-annual plan for the
Expanded Program on Immunization 2011–2015
Strategies 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
How to maintain the regional measles/rubella
elimination?
– Plan of Action to maintain the Regional
elimination of endemic measles and
rubella was approved in the 28th Pan
American Sanitary Conference
Improving access to immunization services
Organizing
Immunization service
delivery
Organizing
the network
of service
providers
Improved
access to IM
service
delivery
Identify the best ways to
increase uptake and the
vaccination coverage
Integrating
immunization
services with
other health
services
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.
NUMBER OF IMPORTED MEASLES CASES BY COUNTRY 2011
Country
Import
Import
related
Argentina
Brazil
1
9
2
24
Unknown
0
9
Chile
3
3
0
Canada*
Colombia
27
1
4
5
772
0
Dominican
Rep.
2
Ecuador
1
Guadalupe** 7
French Guiana 2
0
262
6
3
0
0
1
0
Martinique
Mexico
0
0
1
0
Panama
2
3
4
0
0
United States 111
89
23
Total
398
805
174
Source of Infection
2 cases: D4 ( exposure to French and/or German tourists); 1 case (travel history
to Italy)
D4 (unknown source; recent travel to US); D4 (France), D4, source unknown
D4 (outbreak < 1 case) recent travel to NY and 1 case with a travel history to
Thailand and Malaysia, genotype D9.
India (D8) and D4, France (D4), England (D9); D4 and D9 (unknown source)
1 case with travel history to Brazil
1 case with travel history to Italy D4 / 1 case among a French tourist, it was
confirmed by epidemical link.
No travel history, B3 genotype identified
France
France
France
France, Mexico with a travel history to London); Mexico with travel history to
NYC and Niagara falls, date of rash-onset. D4
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)
* 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
Argentina 1
0
0
Brazil
1
0
9
Canada
3
Colombia 1
Ecuador 0
0
0
69
0
0
0
United
States
23
24
4
Total
29
93
13
Source of Infection
D4 Italy
D4 Portugal,Spain
D4 from India, Uganda,
Pakistan B3, Pakistan
Madrid
B3
The outbreaks >1 case 3
cases, Romania; 14 cases,
Ethiopia (B3), 6 cases Ethiopia
(B3); 4 cases , UK D4)
* 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
Reported MMR1 and MMR2 coverage
Latin America, US and Canada, 2011
100
95%
Coverage (%)
80
60
40
20
0
ARG BOL BRA CAN CHI COL COR CUB DOR ECU ELS GTM HAI HND MEX NIC PAN PAR PER URU USA VEN
MMR1
* Haiti coverage for MR vaccine in children<1 year of age
Source: Country reports through the PAHO-WHO/UNICEF Joint Reporting Form (JRF), 2012
MMR2
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)
Evolution of the outbreak: Confirmed cases of measles
by EW and province, Ecuador 2011-2012 *
8
Santo Domingo
EW 49/2011 (1 caso)
EW 12-13/2012 (3
casos)
3
1
9
ManabÍ
EW 11/2012 (1 caso)
Pichincha
EW 30-51 (34
casos)
EW 3-9/2012 (14
casos)
Cotopaxi
EW 24: 1 caso
EW 41-51 (7 casos)
EW 3-26/2012 (4
casos)
W Tungurahua
2 E 28-48 (163 casos)
EW 3/2012 (1 caso)
6
5
4
Guayas
EW 40-52 (23
casos)
EW 1-3/2012 (14
casos)
Fuente: PAI, Ministerio de Salud Pública de Ecuador.
* Datos a la SE 30/2012
Chimborazo
EW 46-46 (4
casos)
7
Morona Santiago
E W 2-24/2012 (28
casos)
Pastaza
EW 46-52 (25
casos)
EW 2-8/2012 (5
casos)
Confirmed cases: age groups and attack rates
2011-2012
Age
Year 2012
Total
<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
260
69
329
Total
* Per 100,000 populations
Attack rate 2011*
Attack rate
2012*
Year 2011
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
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 : 0
CRS:
 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
Immunization Administrative RR Coverage by
Department,
9-11m, 1-4 y and 5-9 y, Haiti 03-08-2012
100
100 100
100
100.0
100
100
100
100
100
100
100
100
100
100
100 100
100
98.0
100
100
97.0
100
100
96.0
100
100
96.0
90.0
100
100
100
100
100
100
95.0
84.0
80.0
pourcentage
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
Départements
Référence: SIVAC- DEPT
Haiti
RR (9-11 m ) = 100. %
RR (1-4 a ) = 100 %
RR (5-9 a ) = 100 %
Haiti: Sustainability
The 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 incidence
Occurrence 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, ...)
Measles Sequences from Ecuador and Columbia,
2011. Genotype D4 Sequences
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
“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
Ecuador and Columbia,
2011. Genotype B3
Sequences

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