WHAT'S NEW THIS THURSDAY: FIVE ON MEASLES

Monday, 11th of June 2012

• WHAT'S NEW: FIVE ON MEASLES
  
• THE MEASLES & RUBELLA INITIATIVE WELCOMES WORLD HEALTH ASSEMBLY COMMITMENT TO MEASLES AND RUBELLA ELIMINATION GOALS

WASHINGTON, Friday, May 25, 2012 — The global partnership committed to the elimination of measles, rubella and congenital rubella syndrome applauds today’s global pledge to meet measles and rubella elimination goals. One hundred and ninety-four countries resolved their commitment to achieving these goals in the context of a new Global Vaccines Action Plan (GVAP) endorsed today by the World Health Assembly.

The GVAP aims to prevent more than 20 million deaths over the next decade by increasing access to vaccines for all people. The plan is the result of world-wide collaboration and consultation of more than 1,000 immunization experts from 140 countries. Its goals include reducing measles-related deaths by 95% by 2015 and eliminating measles and rubella in at least five of six World Health Organization (WHO) Regions by 2020.

“Today 194 countries have made a fundamental commitment to bring the benefit of vaccination to every person, no matter who they are or where they live.” said Andrea Gay, Executive Director of Children’s Health at the UN Foundation. “This commitment includes eliminating measles and rubella from most of the world by 2020 using proven, cost effective vaccination strategies. The Measles & Rubella Initiative looks forward to working with priority countries and donors to deliver on this global, life-saving commitment.”

Intensified efforts to vaccinate children against measles have resulted in a 74% drop in global measles-related deaths between 2000 and 2010, from an estimated 535,000 down to 139,000.

Measles and rubella elimination strategies have been effective in the Americas which has not recorded an indigenous measles case since 2002 or an indigenous rubella or congenital rubella syndrome case since 2009. The Western Pacific Region aims to eliminate measles next and has made notable progress reducing measles incidence and introducing a combined measles-rubella vaccine in most countries of the region. The European region has pledged to eliminate measles and rubella by 2015 and is working to raise vaccination coverage and stop the measles outbreaks in several countries of the region.

Priority geographic areas for intensified measles and rubella vaccination now include India and sub-Saharan Africa which respectively account for 47% and 36% of global measles deaths. India has strengthened its measles control efforts and is in the midst of a campaign to reach an additional 134 million children with measles vaccine. Sub-Saharan African countries experienced a resurgence in measles outbreaks after 2008 as funds and political commitment to vaccinate children waned. Many countries of the region are now back on track with renewed efforts to ensure every child receives two doses of measles vaccine. The WHO African region aims to eliminate measles by 2020.

Partners in the Measles & Rubella Initiative have recently launched a new Global Measles & Rubella Strategic Plan 2012-2020, which includes strengthening routine immunization as a core strategy. The Initiative has built a measles surveillance system serving most countries of the world which can provide core support to achieving GVAP targets.

“Where there are measles outbreaks we know that routine immunization coverage is simply not high enough,” said Dr. Rebecca Martin, Director of the Global Immunization Division at the U.S. Centers for Disease Control and Prevention. “Surveillance, including the measles laboratory networks can flag the areas where efforts to reach communities with vaccine must be redoubled. This kind of collaboration will reap the full benefits of vaccination everywhere and help the world reduce child deaths to the levels promised through Millennium Development Goal 4.”

For more information, contact:
Hayatee Hassan, WHO, Geneva, +41 79 500 6532, HasanH@who.int
Christian Moen, UNICEF, New York, +1 212 326 7516, cmoen@unicef.org
Alan Janssen, CDC, Atlanta, (404) 639-8517 axj3@cdc.gov
Eric Porterfield, UN Foundation, Washington, DC, +1 202 352 6087, eporterfield@unfoundation.org
Niki Clark, American Red Cross, Washington, DC +1 202 251 8638, Niki.Clark@redcross.org

Links and social media:
Website: www.MeaslesInitiative.org
The blog: https://stopmeaslesrubella.org
More about measles: www.who.int/topics/measles/en
Twitter: @MeaslesRubella
Subscribe to the e-newsletter: http://bit.ly/ICQGJf
Download the Strategic Plan:

 http://bit.ly/IHKuCo or in Ipad format for IBooks: http://bit.ly/meas-rub

• RESEARCH PRIORITIES FOR GLOBAL MEASLES AND RUBELLA CONTROL AND ERADICATION

 

Abstract below; full text is at http://www.sciencedirect.com/science/article/pii/S0264410X12005944

In 2010, an expert advisory panel convened by the World Health Organization to assess the feasibility of measles eradication concluded that (1) measles can and should be eradicated, (2) eradication by 2020 is feasible if measurable progress is made toward existing 2015 measles mortality reduction targets, (3) measles eradication activities should occur in the context of strengthening routine immunization services, and (4) measles eradication activities should be used to accelerate control and elimination of rubella and congenital rubella syndrome (CRS). The expert advisory panel also emphasized the critical role of research and innovation in any disease control or eradication program. In May 2011, a meeting was held to identify and prioritize research priorities to support measles and rubella/CRS control and potential eradication activities. This summary presents the questions identified by the meeting participants and their relative priority within the following categories: (1) measles epidemiology, (2) vaccine development and alternative vaccine delivery, (3) surveillance and laboratory methods, (4) immunization strategies, (5) mathematical modeling and economic analyses, and (6) rubella/CRS control and elimination.

• MEASLES: THE BURDEN OF PREVENTABLE DEATHS

Original Text

Walter A Orenstein a , Alan R Hinman b

 

The Lancet, Volume 379, Issue 9832, Pages 2130 - 2131, 9 June 2012

 

Measles has been, and remains, a major killer of children around the world. Despite the introduction of the measles vaccine in 1963, measles caused an estimated 2·6 million deaths in a single year as recently as 1980.1 In The Lancet, Emily Simons and colleagues2 estimate that, after more than 45 years of measles vaccine availability, the disease caused nearly 140 000 deaths in 2010.

Even in industrialised countries, complications, including pneumonia, diarrhoea, encephalitis, and subacute sclerosing panencephalitis, lead to substantial morbidity and mortality.3, 4 However, it is in developing countries where measles exacts its greatest health burden. A review of community-based measles studies5 showed a median case-fatality ratio of 3·91% (mean 7·40%, range 0—40·15%).

Through global measles prevention efforts, great progress has been made in measles control. Elimination of indigenous transmission of disease has been achieved in the WHO Americas region.1 Five of the six WHO regions have set goals to eliminate measles by 2020. At present, there is a worldwide goal of a 95% reduction in measles mortality by 2015 compared with 2000 estimates. Measles eradication is biologically feasible and, although no formal eradication goal has yet been set, progress toward the mortality reduction goal will lead to consideration of an eradication goal.1, 6

Measles is one of the most contagious vaccine-preventable diseases,7 and is one of the best indicators for problems in vaccination programmes because of its high communicability and recognisable rash. Outbreaks of measles with complications and deaths can be a greater motivating force for change than immunisation coverage data gaps and the theoretical potential for outbreaks.8 This was the case in the USA, where a resurgence of measles in 1989—91 led to major investments in, and strengthening of, the overall National Immunization Program.

If immunisation programmes fail to immunise new susceptibles added to the population daily through births and migration, enough susceptibles will accumulate to fuel another measles outbreak. For example, since 2008, after substantial reductions in measles mortality, measles has resurged in Africa.9 It is crucial to maintain high immunity levels and immunise all children at recommended ages.

How can we best monitor the progress of global immunisation programmes to guide corrective actions if needed? Measuring measles vaccine coverage provides some information but does not directly translate into effects on health burden. Global disease surveillance systems are at present unable to capture measles case numbers accurately enough to monitor deaths directly. Instead, progress has been assessed through changes in estimated annual measles-attributed deaths. As noted by Simons and colleagues,2 65 countries have adequate vital registration data, which allow the measurement of actual deaths. However, for the remaining 128 countries where most deaths from measles occur, vital registration data are inadequate and necessitate the estimation of those deaths.

The accuracy of estimates depends on the assumptions and data used in modelling exercises. Traditionally, it was assumed that all susceptible people acquired measles, so the number of cases depended on vaccine coverage and effectiveness. Once cases were estimated, age distributions were inferred on the basis of coverage, and age-specific case-fatality ratios for a particular region were estimated and applied to the number of cases to estimate the number of deaths.10 Although this approach has been useful for monitoring the progress of measles mortality reduction efforts, there is a potential bias toward overestimating deaths since it does not account for herd immunity, which is likely to decrease incidence of measles and deaths indirectly. Simons and colleagues2 attempt to take this into account by incorporating a decrease in the rate of infection among susceptibles as population immunity rises, and by using actual surveillance data to modify the estimates of cases and mortality (along with other adjustments).2 In so doing, they estimated that that there were 535 300 deaths from measles in 2000, 27% lower than the previous estimate of 733 000.11 Although substantially lower, this estimate still highlights that far too many children are dying from this readily preventable disease. And, in 2010, they estimate 139 300 deaths (382 deaths per day) despite substantial improvements in immunisation coverage.

Most importantly, perhaps, Simons and colleagues' report highlights crucial gaps in available data to guide prevention programmes—surveillance and vital record registrations are inadequate in much of the world. What is most needed is not more advanced ways to estimate mortality, but the direct measurement of mortality. As measles is considered for eradication, it will be crucial to improve surveillance to the point that deaths and cases will actually be measured, not estimated.

We declare that we have no conflicts of interest.

1 Strebel PM, Cochi SL, Hoekstra E, et al. A world without measles. J Infect Dis 2011; 204 (suppl 1): S1-S3. CrossRef | PubMed

2 Simons E, Ferrari M, Fricks J, et al. Assessment of the 2010 global measles mortality reduction goal: results from a model of surveillance data. Lancet 201210.1016/S0140-6736(12)60522-4. published online April 24. PubMed

3 Strebel PM, Papania MJ, Dayan GH, Halsey NA. Measles vaccine. In: Plotkin SA, Orenstein WA, Offit PA, eds. Vaccines. Philadelphia: Saunders Elsevier, 2008: 353-398.

4 Orenstein WA, Papania MJ, Wharton ME. Measles elimination in the United States. J Infect Dis 2004; 189 (suppl 1): S1-S3. CrossRef | PubMed

5 Wolfson LJ, Strebel PM, Gacic-Dobo M, Hoekstra EJ, McFarland JW, Hersh BS. Has the 2005 measles mortality reduction goal been achieved? A natural history modelling study. Lancet 2007; 369: 191-200. Summary | Full Text | PDF(1261KB) | CrossRef | PubMed

6 Bellini WJ, Rota PA. Biological feasibility of measles eradication. Virus Res 2011; 162: 72-79. CrossRef | PubMed

7 Fine PEM, Mulholland K. Community Immunity. In: Plotkin SA, Orenstein WA, Offit PA, eds. Vaccines. Philadelphia: Saunders Elsevier, 2008: 1573-1592.

8 Orenstein WA. The role of measles elimination in development of a national immunization program. Pediatr Infect Dis J 2006; 25: 1093-1101. CrossRef | PubMed

9 Moss WJ, Griffin DE. Measles. Lancet 2011; 379: 153-164. Summary | Full Text | PDF(1370KB) | CrossRef | PubMed

10 Wolfson LJ, Grais RF, Luquero FJ, Birmingham ME, Strebel PM. Estimates of measles case fatality ratios: a comprehensive review of community-based studies. Int J Epidemiol 2009; 38: 192-205. CrossRef | PubMed

11 Centers for Disease Control and Prevention. Global measles mortality, 2000—2008. MMWR Morb Mortal Wkly Rep 2009; 58: 1321-1326. PubMed

a School of Medicine and Emory Vaccine Center, Emory University, Atlanta, GA 30322, USA

b Center for Vaccine Equity, Task Force for Global Health, Decatur, GA, USA

Access this article on SciVerse ScienceDirect

 

• ASSESSMENT OF THE 2010 GLOBAL MEASLES MORTALITY REDUCTION GOAL: RESULTS FROM A MODEL OF SURVEILLANCE DATA

The Lancet, Volume 379, Issue 9832, Pages 2173 - 2178, 9 June 2012

 

Full text is at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60522-4/fulltext

 

Summary

Background

In 2008 all WHO member states endorsed a target of 90% reduction in measles mortality by 2010 over 2000 levels. We developed a model to estimate progress made towards this goal.

Methods

We constructed a state-space model with population and immunisation coverage estimates and reported surveillance data to estimate annual national measles cases, distributed across age classes. We estimated deaths by applying age-specific and country-specific case-fatality ratios to estimated cases in each age-country class.

Findings

Estimated global measles mortality decreased 74% from 535 300 deaths (95% CI 347 200—976 400) in 2000 to 139 300 (71 200—447 800) in 2010. Measles mortality was reduced by more than three-quarters in all WHO regions except the WHO southeast Asia region. India accounted for 47% of estimated measles mortality in 2010, and the WHO African region accounted for 36%.

Interpretation

Despite rapid progress in measles control from 2000 to 2007, delayed implementation of accelerated disease control in India and continued outbreaks in Africa stalled momentum towards the 2010 global measles mortality reduction goal. Intensified control measures and renewed political and financial commitment are needed to achieve mortality reduction targets and lay the foundation for future global eradication of measles.

• NOTES FROM THE NATIONAL WRAP-UP MEETING, UGANDA'S INTEGRATED MEASLES/POLIO CAMPAIGN

On Wednesday, 13 June 2012, the Ugandan Ministry of Health did a self-examination of the just completed integrated measles/polio campaign, covering all 112 districts of the country.

 

In this meeting, several hardy perennials sprouted. Messaging was right: all stakeholders referred to the campaign as for under-fives, not, ambiguously, as for ‘up to fives.’ Funds flow was late in parts of the country, and some vaccinators withheld their tally sheets while waiting for payment. The campaign would have gone better if all items had been pre-positioned well in advance. One 2 year old girl choked on her albendazole tablet. Could staff be trained to treat such rare cases?

 

Two decisions face Uganda in 2012, the year of its next triennial measles campaign:

 

1)      Will it give measles or measles/rubella vaccine? If the latter, then with likely GAVI funding

2)      If Africa goes for global eradication, will house to house social mobilization be needed to achieve 95 percent coverage in all districts?  How much is the price tag on this highly effective strategy?

 

 

The acting UNEPI Director opened the meeting, which brought together >40 participants from the government and partners. This is a joint meeting between the NCC and the central MoH team, as well as Red Cross, USAID, WHO and UNICEF.

 

After the opening prayer and introductions, the D-G welcomed all participants.  She hoped that the field teams were bringing back good news from the field. She thanked the organizers of the launch, which covered EPI, ivermectin mass drug administration (MDA), and Child Days Plus.  She thanked the UNEPI team and partners for their good work, especially the social mobilization team. This campaign was on the radio every minute. National Medical Stores was of great help, with pre-positioning of vaccines and supplies one week before the campaign start.

 

Challenges: The National Co-ordination Committee held a number of meetings; the NCC had to postpone the campaign once. However, funding issues still came up, and we have not met our obligations in all districts. We thank all the districts, funded and unfunded, for their hard work. We lost a two-year-old girl during the campaign. This was from asphyxia from albendazole in her airway. We need to emphasize that the children start with the oral preparations first, then the injections.

 

We shall go straight to our program.

 

Jacinta, the acting UNEPI programme manager gave a presentation on the campaign results, based on submissions from districts and campaign supervisors.

 

The 2011 RI coverage was 75 percent for measles. We got into outbreaks before the SIA.

The NCC (national coordinating committee) operated with wide membership, using five subcommittees.

Supervision was done from central and district levels, including participation of district leadership.

 

The dates were 26 through 28 May, with press release by Hon Minister of Health, with launch by President Museveni in Pader District, with 112 districts implementing and two days of mop-up; Kampala mop-up is still pending.

 

One district, home to the Namayuingo Islands, was phased.

 

Results from the districts which have thus far reported:

 

Measles                                                           OPV

 

	Measles	OPV
>100 percent	48 districts	52 districts
95-100 percent	12	7
85-95 percent	6	6
50 to 85 percent	10	11
Reporting districts	76/112	76/112

 

 

Support: WHO, UNICEF, RC, DFID, USAID, LDS, Rotary, Lions Club, NMS

 

The Sironko District presentation discussed special efforts for those areas where vaccines are regarded as demonic. The local councillors, LC1s, did house to house mobilization district wide. Health workers were mapped by subcounty. This district reported no severe AEFI. The LC1s participated in the mop-up, which started on Saturday, 9 June. Mop-up was limited to subcounties without vaccinated children. Best practices: efforts by all stakeholders to mobilize the population. Challenges: late receipt of funds for mop-up; inadequate tally sheets.

 

Overall coverage was 101 percent, but with variations by subcounty. There were 8/21 subcounties reporting <100 percent for measles, largely where there were religious objections.

 

Isingiro District, recently created, reported difficulties with funds flow. Both polio and measles coverage exceeded 100 percent. In some areas, social mobilization from the government side was not active. Social mobilization went well where UNICEF funding was present. Cold chain and freezing capacity were well done; there were spot shortages of measles vaccines at some sites. All materials were available; where stockouts occurred, this was because of poor distribution. Injection safety was well done. Waste management was not adequate. We had no serious AEFI. We had adequate albendazole and vitamin A. Funding was not available for mop-up. Best practices: early freezing of icepacks, which were refrozen at day’s end for the following day.

 

The way forward: register all children so that we can identify those missed.

 

Coffee Break

 

During the coffee break, the UNICEF SIA consultant said that he would like to have seen coverage estimates for below the district level. The parish data might be telling a different story from the grouped district figures.

 

WHO report, Andrew Bakainaga

 

Independent monitoring (IM) data are not yet available; our monitors complete their work this Friday. We worked on monitoring and supervision, covering Kampala and four other districts. We noted that in all regions with WHO participation, all districts had completed the microplanning process. The microplans formed the basis of the budgets. The CAOs were critical in financing the campaign, especially where funds flow was late, as in the South. This led to prompt start on the 26^th. The leadership and commitment of district health officers was remarkable in most districts. There was a great involvement of the political leadership, especially the local councillors, LC5s. Implementation funds arrived late in many areas. The microplans were not translated into operational plans, e.g., detailed distribution plans. We also realized that in some districts, there were hard to reach areas (whether from geography or difficult to convince populations); plans to reach these were not well defined or implemented.

 

Some launches, including the presidential launch, for the nodding disease campaign brought the SIA to the fore. The local councilors assisted with refusals. Radio talk shows were heard in most districts. There were, in general, enough frozen icepacks, vaccine carriers.

 

There was high demand everywhere, especially on Days 2 and 3. In some districts, local councilors did preregistration and defaulter follow-up, which contributed to high coverage. On Sunday, sites were assigned to places of worship.

 

Weaknesses: Training was not done for lack of funds; IM admin of measles, erroneous finger marking, weaknesses in deployment of mobile teams for remote areas. Most districts had not received IEC materials, such as flyers. Some districts were short of transport for supervision. In some districts, there were shortages of diluent on Day 2. Some districts did not get cards and tally sheets, which presented challenges. There was a shortage of vitamin A and albendazole, as well as Child Day tally sheets.

 

The way forward: The future campaigns should have dates set after confirmation of funds availability, as distinct from pledges. Social mapping of rejectionists, especially in Mbale, is necessary. The IEC materials were often wasted because of late distribution. Prepositioning, 2 weeks in advance, is needed. If this problem persists, use your social mobilization funding in other areas.

 

Districts should be encouraged to develop operational plans, based on the microplans. There is a need for early involvement of faith based organizations (FBOs) and traditional leaders, to avoid religious objections to vaccination.

 

Maldistribution of supplies from the district to the field points to the need for developing distribution plans to avoid overstocking and stockouts.

 

Eva Kabwongera introduced their polio consultant and Bonifacio Raul, the measles SIA consultant, who presented. UNICEF supported 7 geographical areas.

 

Planning and coordination

Strengths:

• Microplans developed in all areas
• Coordination meetings took place
• Strong coordination with local partners/NGOs on social mob and transport
• Few mobile posts in hard to reach areas

 

Challenges

• Late arrival of funds
• No ops plans

Top down microplans not translated at parish level

 

 

Social mobilization

 

Strengths:

 

• LC5s and RDCs, district commissioners, involved in mobilization
• Most districts conducted radio talk shows
• Most moms heard about the campaign through radio and LC1s.
• High demand on Days 2 and 3
• Announcements in churches and mosques
• Preregistration done before the campaign by LC1s

 

Challenges:

• Social mob funds came late.
• Most districts did not get IEC materials.

 

 

Cold Chain

Strengths:

• Vaccines and supplies according go to microplans
• All VVMs were OK
• Adequate vaccine carriers and icepacks

 

Challenges:

• Shortage of transport
• Shortage of vitamin A capsules, deworming tablets
• Stockouts of vaccines and other supplies in some areas

 

Monitoring and supervision

 

Strengths:

Tally sheets used systematically

 

Challenges:

 

• Supervisors arrived late
• Data not used to guide next day’s activities
• No plan to collect data on time
• Some vaccination sites did not have tally sheet
• One AEFI case reported

 

Implementation

 

Strengths:

 

• Measles vaccination done by HWs, health workers
• Good vaccine management seen
• Post organization well maintained

 

Challenges:

• Most posts started late on Day 1
• Gaps in registration of clients

 

Best practices:

 

• Strong government commitment and involvement
• LC2 and village health teams had active role in social mobilization
• Preregistration of target children, good exercise
• Local resource mobilization filled the gaps

 

Recommendations:

 

• Bottom up microplan exercise, including social mapping
• Resources should arrive in the districts well ahead of any campaign to ensure effective implementation.

 

John Barenzi presented on behalf of the Uganda Red Cross Society.

 

URCS was involved with support from Amcross. We worked in 14 districts, including Kampala and Wakiso. In the upcountry districts, things went well. In Kampala, there were problems. We have a coordinator and a mobilizer in each of the capital’s five divisions. We were able to assemble a team of young people. We tried to align our services with those of LC1s, moving house to house to inform the public. The participation of LCs in Kampala was lukewarm. They expected payments, which were not forthcoming. URCS supported KCC and upcountry with transport, loaning one vehicle to each upcountry district. In Kampala, we still had only two vehicles for the capital, which was inadequate. H2H mobilization was done before the campaign so they would come in starting on Day 1. The H2H mob was not total, since 579 volunteers were not enough to cover the entire population. We did a quick survey to look at the percentage of mothers were informed by the mothers. URCS trailed radio, which was first, as a maternal information source.

 

Challenges: Many vaccination centres opened late or not at all. There was miscommunication. Some volunteers expected transport to centres. Covering the largest, high volume centers with a single volunteer was not adequate. HWs were not content because of non-payment. Many were unwilling to hand in their tally sheets. The quality of vaccination services was poor. The diluent was sometimes set on the table. Injections were intramuscular in many cases. This shows that training was hurriedly done. URCS will participate in the Kampala mop-up this weekend.

 

There was no LDS presentation.

 

The Lions Club did not present.

 

The mass drug administration team (MDA) did not present.

 

The Office of the Prime Minister spoke next. The RDCs, resident district commissioners, have a constitutional mandate to monitor all activities in their districts.  They reported successful implementation, despite challenges, such as shortages of drugs (albendazole and vitamin A), and, in Nguru District, use of minors as caregivers. In one district, bad roads hampered movement of health workers. In one district, born again churches objected to the vaccinations. As UNICEF said, there has to be enough advance preparation to make sure that things go well.

 

Child Days Plus presented next.

 

The polio and measles campaign were to merge with Child Days Plus. However, some districts started CDP before the 26^th. Moreover, some districts did not have CDP tally sheets. Because timing was not uniform, monitoring was sometimes difficult. All the same, we appreciated the operation. CDP should have waited in some districts. Logistics were present in some district, absent in others. Our most serious problem was stockouts of albendazole. The distribution mechanisms were poorly developed.

 

Discussion

 

Patrick Isingoma spoke as a district supervisor. The Stanbic Bank supported the launch in one subcounty. We found it hard to reach the market women and used the Lions to bring them in.

We had a needlestick injury in one site. The HW mishandled the situation.

 

Another discussant: how can you have many children unvaccinated in districts with coverage over 100 percent?

 

Bob Davis said:

 

1)      In Uganda as elsewhere, funds flow and prepositioning of supplies were major challenges.

2)      The messaging in Uganda was consistent: under-fives. This is a lesson for other countries.

3)      TV, radio and house visits were all important. Printed items (flyers, brochures, banners, posters) were mentioned by <2 percent of all caregivers in Kampala.

4)      Mass media do not reach non-owners of radios and TVs. More systematic house visiting is needed.

5)      LC1s have to get on board, in future, for preregistration and defaulter follow-up.

6)      Red Cross deployed 1000 volunteers in Dar es Salaam, which was enough. In Kampala, 579 volunteers were insufficient to cover all households.

 

One participant: Some religious communities, as noted in previous campaigns, resist vaccination, especially but not exclusively in western Uganda. The Director of Clinical Services should take up this problem.

 

Another participant, central store supervisor: Our problem was funds. HWs hid their tally sheets awaiting payment.

 

We had three suspected AFP cases. Samples were taken.

 

We had one AEFI case in one center. The child recovered after sweating on the lip.

 

Wherever I went, the health workers were poorly trained. They did not know how to record zero doses.

 

Another participant: In Moyo, on the South Sudan border, they got coverage >100 percent. However, we had people from outside getting shots in these places, which explains the overestimates. It doesn’t matter where a child is vaccinated, if s/he is vaccinated.

 

We had some Sudanese coming to Moyo early in the morning.

 

The local councillors asked for money, to which they are no longer entitled.

 

Participant from Karamoja: I saw few IEC materials in Kotido. The deliveries of IEC materials were not made. These are still in the store.

 

Another participant: Urban areas were sometimes hard to reach because of resistant Somalis and Karamojong. We used the mosques to correct false impressions.

 

Where coverage exceeds 100 percent in border areas, this is, for example, because of Kenyans coming into Busia. In Busia, LC1s got money from CAOs as an incentive.

 

In one district, we used LCs successfully to speak with refusers. LCs motivated mothers to get shots by telling mothers that the EPI card was a prerequisite to accessing government health facilities.

 

John Barenzi: We are considering increasing the number of volunteers deployed to the slums. Now that we have supported the upcountry transport, we will deploy one vehicle for each of the five divisions in Kampala.

 

Another participant: In a Millennium Village district, the services were quite efficient. The HW is quite good, and coverage was high.

 

In another district, there were many zero doses. This does not mean that the campaign was a failure, but that it made up for the failures of RI.

 

Eva Kabwongera: There was a big problem with IEC materials distribution for Karamoja. Logistics were a problem in the campaign.

 

PM’s Office rep: When the RI falls short of a certain level, the answer is to respond with mass immunization. We must go beyond this discussion. Why have we seen declines in health facility deliveries? How do we return to better use of routine health services? This is a cross cutting issue, not just touching EPI. You use the RDC and the LC5 to revive routine services.

How do we overcome religious objectors?

With more access to cash, there is a decline in voluntarism.

On cross border districts, you will see people coming. This is good, because it prevents cross border measles transmission.

 

A district supervisor: In Adere, we had poor coverage on Day 1. We used all means at our disposal, including teachers and pupils, to look for unmarked children. Any village without marked children was targeted for mobile teams.

 

Mass drug administration, done at household level, limited frequentation of fixed posts, which gave OPV and measles.

 

We counted vials against tally sheets to find inconsistencies in tally sheets.

 

There were no scissors to open the vitamin A capsules. People used fingers to pinch the capsules.

 

In the subcounty with the presidential launch on Day 1, coverage shot up on Day 2.

 

Mop-ups were highly successful, with coverage at 96 percent by Day 2 of the mop-ups.

We saw subcounty figures which were not consistent with the data from the districts of which they formed a part.

 

Another participant:

Challenges in Kampala: much of Wakiso is similar to Kampala. Should these areas be treated like Kampala for mop-up?

Diluent: some centers hold diluents to use as water for injection. This is incorrect. Let’s explore this.

Targets: we are not using correct denominators. This is why coverage exceeds 100 percent in some places. Let’s review the 21.4 and 19.2 percent, respectively, as OPV and measles proportions.

 

Another participant, from Mitoma:

Let’s do more convenience monitoring.

There was one arrest of a police officer who tried to charge EPI Sh 10,000 for car parking in the police compound.

 

Another participant, from Kumi district:

There are some objections to finishing Child Days, then starting measles SIAs the next week. Why this heavy overlap in services between CDs and SIAs? Once these are completed, should routine outreach continue?

 

UNEPI manager, responding: We use 20.5 percent for OPV and 18.5 percent of total population for calculating  target populations  for measles. We use the same denominators for all 112 districts.

 

We revaccinate because MCV1 at 9 months produces only 85 percent efficacy.

 

Refugee camp vaccination is difficult when children are trucked from site to site. We have used district authorities to halt the premature dispatch of unvaccinated kids.

 

Mbarara supervisor: Training was lacking. They were injecting IM instead of subcutaneously. Nursing assistants were doing better than nurses! (groans from the audience) We need to look at how to improve training for future campaigns.

 

Shema district supervisor: the LC5 and LC3 did not participate because of problems with the CAO. These guys were recommending the CAO for transfer. The HWs have not yet been paid. The HWs are bitter because of nonpayment.

 

Amuru and Moya district supervisor: Coverage was about 100 percent, but I’m not sure of this figure. We had many challenges in both districts [detailed account]

 

Afternoon Sessions

 

One participant: Kampala vaccinators were not paid, and hence refused. KCC voted to use students, and those students were not paid.

 

One district supervisor: Prepayment of vaccinators creates headaches. It is hard to get data from them when you have no stick with which to beat them.

 

Another district supervisor: we had much success with the H2H social mobilization. In lakeside areas, we needed more motorcycles.

 

In Kasesa, we needed 4WD vehicles to reach hard to reach areas.

 

Another district supervisor: we saw a school outbreak of 11 suspected measles cases in children aged 5 to 11.  We followed WHO advice in taking blood samples.

 

Acting UNEPI Director, Best practices

 

1 High level political advocacy

• Constant support from top management
• District political and civil support
• Participation of district leadership in coordination meetings, mobilizing resources, grass roots mobilization

 

2  Multi sectoral planning at national and district level

 

3 HPAC and HDP, especially in the area of res mobilization

 

4 Media support before, during and after implementation

 

5 Community valuing health, high demand

 

6 Cascading supportive supervision

 

7 Committed HWs and mobilizers

 

8 Build capacity for the districts to conduct training for their own HWs and mobilizers

 

9 Integrated child survival interventions increased demand for the campaign.

 

Challenges:

 

1 Resistant religious sects

 

2 Challenges in distribution of IEC materials

 

3 Influx of kids from neighboring countries

 

4 Influx of refugees from DRC

 

5 Delayed funding, resulting in

• Gaps in training
• HWs refusing to hand in results because of delayed payment
• Incidence of hostility towards district health teams and central supervisors due to delayed payment
•  

6 Delayed departure of central teams due to delayed release of funds

 

7 Distribution of logistics at district level and below, mostly due to transport challenges

 

8 Inadequate transport at central level contributed to delays in delivering monitoring tools

 

9 Inadequate coordination of MoH programs

 

10 Challenge of denominator (UBOS projected much lower than the actual pop)

 

11 Challenges of human resources

 

12 Death of 2 year old from asphyxia after taking albendazole

 

Way forward:

 

1)      Use LCs to register all children in their jurisdiction

 

2)      Develop health communications strategy for UNEPI and Child Health

 

 

3)      GoU should make by-laws on vaccination

 

4)      Do mapping of unvaccinated and resistant populations.

 

 

5)      Work with MoE and Ministry of Sports – school entry requirement

 

6)      Mothers to bring in EPI cards for medical services

 

7)      Emphasize integration.

 

 

8)      Do ongoing training of HWs.

 

9)      Give feedback to the different key stakeholders.

10)  Engage CAOs for RI and campaigns.

 

11)  Specific interventions to reach hard to reach populations.

 

 

12)  Liaise with UBOS to revise targets.

 

13)  Fix dates once we are sure we have resources (pool resources, basket funding)

 

 

14)  Review the fixed posts based on the district circumstances.

 

15)  Harmonize messages.

 

 

16)  Identify low performing districts for early implementation of the RED approach.

 

17)  Involve regional member states collectively to implement.

 

 

18)  Revitalize outreach circuits for RI.

 

19)  Supervision should start with training.

 

 

20)  Reactivate the committees responsible for supervision.

 

21)  Increase T-shirts.

 

 

22)  Revise HWs’ allowances and transport.

 

23)  Increase the number of HWs.

 

 

24)  Use PA system in urban areas.

 

25)  Increase SIAs from 3 days to 4.

 

 

26)  Train CHWS to give at least OPV.

 

27)  Train HWs in emergency care for, e.g., asphyxiation.

 

 

28)  Budget fuel, etc. for hard to reach areas, especially islands.

 

29)  Newly created posts should be maintained.

 

 

30)  Hold quarterly review meetings of central supervisors.

 

31)  Assure early release of funds.

 

 

32)   Train HW for hard to reach areas.

 

33)  Create cold chains in newly created districts.

 

 

34)  Follow up on payments of health workers who implement SIAs

 

35)  Carry out bottom-up planning, especially at the parish level.

 

 

36)  Continuous funding to the health worker

 

37)  MoH to advocate for transport, helicopters to reach hard to reach areas

 

 

38)  Strengthen surveillance.

 

 

 

 

Caregivers’ Source of Information

I communicated the following information, from interviews with caregivers at vaccination sites.

1)       TV and radio, in both English and Luganda, came in first as information sources. DHS data (see  Table 2) show that mass media are necessary but not sufficient.

2)       House visits (by Red Cross and other partners, such as the LDS Church) reached some persons not accessible by the mass media.

3)       The little used megaphones did well; more expenditure on these might have generated a greater yield.

4)       Print media and printed items, including newspapers, posters, flyers, and banners, played an insignificant role.

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