Measles and Other Vaccine Preventable Diseases in Emergencies

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Measles and Other Vaccine Preventable Diseases in
Emergencies
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Outline

• Measles vaccination in the region
• Measles epidemiology in emergencies
• Detecting an outbreak
• Responding to an outbreak
• After the outbreak
• Other vaccine preventable diseases
• Case study, measles in Afghanistan

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Cause of Death Worldwide Among Children lt5 Years,
2000-2003
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Major Causes of Death in emergencies for lt5 Years
Sudan Wad Kowli Camp February, 1985
Somalia Gedo Region 7 Camps, January, 1980
Measles ARI Malaria Diarrhea Other
Source Centers for Disease Control and
Prevention, Famine-Affected, Refugee, and
Displaced Populations Recommendations for Public
Health Issues. MMWR, 199241(No. RR-13)8.
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WHO/UNICEF estimates for MCV1 coverage
2001-05Regional coverage increased from 59 in
1999 to 65 in 20051
Source WHO/UNICEF estimates
1Acknowledgements Jayantha Liyanage, Medical
Officer- EPI, Immunization and Vaccine
Development WHO/SEARO
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Serious Complicationsof Measles
Encephalitis
Conjunctivitis, Keratitis, Blindness
Sore mouth, Gingivostomatitis
Laryngotracheobronchitis
Bronchopneumonia
Enteritis, Diarrhoea
Source D. Morley, Proc Roy Soc Med 1974 674-7.
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Mortality in Refugee and Displaced Populations

• Major causes of death in the emergency phase
• Measles
• Diarrheal disease
• Acute respiratory infections
• 50 - 90 of deaths in some refugee settings due
  to these 3 diseases

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Measles Case Fatality Ratios Reported in
Emergencies
Stable populations 1-10 Emergencies 2-21
(up to 33 reported)
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What are the Factors that Increase Measles
Mortality in Emergencies?
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Risk Factors For Severe Measles Disease

• Malnutrition
• Vitamin A deficiency
• Exposure to higher viral loads
• Young age (6-9 months)
• Poor access to case management of complications
• HIV infection

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Measles Epidemiology in Emergencies

• Age distribution of reported measles cases,
  Afghanistan 2001(N8,720)

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WHO Recommended Vaccines For Routine EPI
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Measles The Vaccine

• Live attenuated vaccine
• Vials 10, 20 dose most with VVM
• Must be reconstituted with own diluent
• Must be discarded six hours after reconstitution
• Heat sensitive especially after reconstitution
• Given subcutaneously in the upper arm
• What is measles vaccine efficacy at
• Nine months?
• Twelve months?

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Measles Vaccine Efficacy

• Vaccine efficacy (VE)
• At 9 months 85
• At 12 months 95
• Vaccine effectiveness
• Cold chain/administration
• Immunity lifelong
• Vaccination immunity

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Preventing Measles Illness and Death in
Emergencies

• Prevent or detect the outbreak
• Vaccination
• - Timely, high quality mass campaigns in
  emergencies
• - Routine childhood vaccination
• Appropriate treatment of illness
• - Vitamin A
• Infants lt6m 50,000 IU repeat next day
• Infants 6-11m 100,000 IU repeat next day
• Children 1y 200,000 IU repeat next day
• - Antibiotics for bacterial secondary infections
• - Treat dehydration

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Measles Vaccination in Emergencies

• What is the recommended age range for measles
  vaccination in emergencies?

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Measles Vaccination in Emergencies

• Age range
• - 6 months to 15 years
• Revaccinate
• - Those who receive vaccine at 6-9 months
• Others
• - Older children or adults if cases within that
  age group

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Measles Vaccination in Emergencies

• In rare cases if have to prioritize
• Undernourished or ill children lt15 years
• Any child 6-23 months old
• All others 24-59 months old
• Those without parents
• All others 6-15 years old
• WHEN IN DOUBT VACCINATE!

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Common Misconceptions About Measles Vaccination

• Vaccinating a child with a possible or unknown
  history of measles infection
• Vaccinating an ill or malnourished child
• Including HIV positive
• Occurrence of measles case taken as a
  contraindication to vaccinate

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Detecting an outbreak

• In emergencies one case is an outbreak
• Have simple standardized case definition
• Generalized rash lasting gt3 days and temp gt38 C
  and 1 of following cough, runny nose, red eyes
• Surveillance in clinics and if possible the
  community (can use local term)
• Monitor surveillance data
• Active better than passive surveillance

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Detecting an Outbreak

• Establish chain of notification and investigation
• Report to MOH/WHO immediately
• Name
• Age
• Sex
• Vaccination status

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Measles Outbreak Darfur, SudanMay-September 2004
Vaccination Campaign
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Other Vaccine Preventable Diseases in Emergencies
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Routine EPI Antigens in Emergencies

• BCG
• WHO schedule at birth
• Efficacy
• Only prevents spread from lungs
• Doubtful for adults (0-80)
• Better in preventing disseminated disease in
  children (56-90)

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Routine EPI Antigens in Emergencies

• OPV
• WHO schedule Birth, 6, 10, 14 weeks
• Birth dose does NOT count
• Target population in refugee settings 0-59 months
• Importance in refugee settings
• Refugees may constitute a high risk group
• Efficacy three doses 95

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Routine EPI Antigens in Emergencies

• Diphtheria, Pertussis Tetanus (DTP)
• - WHO schedule 6, 10, 14 weeks
• - Target population in refugee settings 6 wks-5
  years?
• - Minimum of four weeks between doses
• Importance in refugee settings
• - Not in emergency phase, but implement as soon
  as possible. Must be able to deliver three doses
• - Efficacy three doses 90
• Diphtheria may be a consideration in some
  countries
• 4th booster dose necessary for protection

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• Pop Quiz

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Routine EPI Antigens in Emergencies

• Tetanus Toxoid (TT)
• - At least 2 doses prior to delivery
• - At least 4 weeks between doses
• - Target population in refugee settings all
  women aged 15-49 years
• Importance in refugee settings?
• - Not in emergency phase, but a high priority
  immediately afterwards
• - Neonatal tetanus is targeted for elimination
• Efficacy
• - 100 efficacy, booster every 10 years

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Yellow Fever Vaccine

• 1 dose 95 immunity
• Safe local/mild reactions, 2-5
• WHO recommends routine YF vaccination in 35
  African countries at 9 months
• Contraindicated in children lt4 months
• Limited quantity available - short shelf life
• Central cold storage 200C, peripheral 4-80C

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Other Vaccines

• Meningitis

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Role of Different Partners During a Measles
Campaign in Emergencies

• Outbreak Confirmation MOH/WHO
• Vaccine and perhaps cold chain equipment
  MOH/UNICEF
• NGO partners
• Often first to report case
• Case management in clinics
• May be asked to take responsibility for whole
  campaign
• Often asked to provide
• Supervisors external monitors
• Vaccinators
• Transport
• Assist with social mobilization

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Develop A Microplan

• Take responsibility for a distinct administrative
  unit such as a county or district
• Involve
• The county or district medical officer
• All other health NGOs in the area
• Non health NGOs
• Local district officials
• Religious groups

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Elements of a Good Microplan

• Well defined campaign location
• Recent population data by town, village
• Inclusion of IDP populations
• Identification of hard to reach populations
• Dont forget hospitals, supplementary feeding
  centers, food distribution centers
• Condition of roads, bridges, waterways, airstrips
• Identification of insecure areas

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Microplan Essential Background Information
Infrastructure and Manpower

• Existing cold chain equipment
• Cold boxes, vaccine carriers, ice packs
• Functioning freezers and fridges
• Electricity sources
• Functioning facilities
• trained vaccinators, supervisors
• Available vehicles/motorcycles
• Vehicles/motorcycles for hire

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Calculating Staff Needs Number of teams

• Target population 45 of total population
• Children per day
• Urban areas 300 children/team/day
• Rural areas 150 children per day
• Difficult areas 50-100 children per day

Teams total population X 0.45
children per team day X days
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Team Composition and Roles

• Vaccinators (2)
• Screener and vitamin A administrator (1)
• Recorder for measles and vitamin A (1)
• Social mobilizer (1)
• Organizer (1)

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Calculating Staff Needs Supervisors and
Coordinator

• A supervisor must be able to really supervise
  each team
• Example from Liberia
• At least one coordinator at county level
• At least one coordinator for each district
• Cold chain supervisor for each vaccine depot
• Monitors from central and local level
• Overall logistics manager

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Calculating Supply Needs Vaccine

• Doses of measles vaccine and diluent
• doses target population wastage reserve
• Wastage 15 so loss factor 1.17
• Doses needed target X 1.17 20 reserve

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Calculating the Loss Factor

• The target population 100 children
• If wastage is 15 then we need 115 doses
• However, we will also lose 15 of the extra 15
  doses 2.25 doses
• To vaccinate 100 children we need 100 15 2.25
  doses, 117.25 doses
• The loss factor is 1.17

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Calculating Supply Needs Injection Materials

• Number of vials doses needed/10
• Diluent number of vials
• Syringes and needles for dilution vials
• AD syringes Doses needed
• Safety boxes
• AD syringes syringes for dilution
• 100

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Calculating Supply NeedsVitamin A

• Target population 6-59 months
• 6-12 months 100,000 IU
• 10 of children aged 0-59 months
• 12-59 months 200,000 IU
• 80 of children aged 0-59 months
• Add a 10 reserve
• 1 scissors per team

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Calculating Cold Chain Needs Example from South
Sudan

• Vaccine carriers at least 2 per team
• 1 for vaccine 1 for extra icepacks
• Cold boxes 1 for each storage depot
• Icepacks vaccine carriers X 4 large cold
  boxes X 50
• Fridges, freezers?
• Fuel for generator (icepacks need to be frozen
  3-5 days before campaign)

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CalculatingTransport Needs Liberia

• Transport for supplies
• Vaccine supplies from Monrovia to county
• From County District Depot
• Re-supply to teams
• At end supplies, results back to Monrovia
• Transport for teams, supervisors, coordinators,
  monitors
• Fuel for vehicles
• Service for vehicles
• Hire of vehicles

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Other Supply Needs

• Pens
• Talley sheets
• Measles
• Vitamin A
• Summary reporting sheets
• Supervisor checklists
• Monitor checklists
• Plastic bags for vials, vitamin A capsules

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Training Needs

• Microplanning meeting
• Training of trainers workshop
• Refresher vaccinator training (no more than 60
  persons per training session)
• Training materials
• Social mobilization materials
• Messages for criers
• Posters
• Megaphones batteries

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Essential Activities During the Campaign

• Find unvaccinated children
• Monitor cold chain rigorously
• Monitor injection safety
• Implement AEFI system
• Troubleshoot effectively
• Verify incineration of safety boxes

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Essential Activities After the Campaign

• Collect and review all tally sheets
• Send summary reporting sheets to MOH
• Collect and review all supervision documents and
  return them to MOH
• Identify missed pockets
• Plan for mop-up
• Continue to monitor for AEFI (especially
  injection abscess)

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Essential Activities After the Campaign Contd.

• Evaluate coverage
• Review and share lessons learned
• Develop plan to vaccinate those 6-9 months
• Continue good surveillance

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Ongoing Vaccination Activities Vaccine Delivery
Strategies

• Emergency phase
• New arrivals
• Vaccinate upon arrival
• At all entry sites
• Vaccinate at food distribution and other supply
  sites
• Vaccinate at supplementary feeding sites
• Distribute Vitamin A

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Ongoing Vaccination Activities Vaccine Delivery
Strategies

• Long term
• Site location
• With or near feeding centers
• Prenatal clinic
• Well/sick care site
• Traditional health clinics

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Ongoing Vaccination Activities Vaccine Delivery
Strategies

• Long term
• Determine the frequency of service
• Depends on
• Cold chain equipment
• Population
• Supplies
• Staff resources

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Ongoing Vaccination Activities Vaccine Delivery
Strategies

• Long term
• Tracking
• Monitor and recall dropouts
• Monitor newborns
• Enroll when 9 months
• Monitor new arrivals
• Monitor new enrollees at feeding centers

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Ongoing Vaccination Activities Vaccine Delivery
Strategies

• Long term
• Vaccinate during other health care visits
• Vaccinate simultaneously
• Follow only true contraindications
• Catch-up campaigns
• Periodic coverage surveys