Measles Catch-up Campaign Bangladesh & Pakistan Quamrul Hasan WHO - Pakistan.

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Measles Catch-up Campaign Bangladesh & Pakistan Quamrul Hasan WHO - Pakistan

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Transcript of Measles Catch-up Campaign Bangladesh & Pakistan Quamrul Hasan WHO - Pakistan.

  • Measles Catch-up CampaignBangladesh & PakistanQuamrul HasanWHO - Pakistan

  • Campaign Target & Achievement

    PakistanBangladeshTarget agePhase 1: 09 months to less than 15 yrsPhase 2 to 5: 09 months to less than 13 yrs09 months to less than 10 yrsPhase wise target & achievement (administrative data)TargetAchievementCoverageTargetAchievementCoveragePhase 12,571,5362,511,83798%1,481,3211,374,39093%Phase 21,219,3641,282,232105%34,199,59034,637,764101%Phase 36,890,6036,906,376100%Phase 421,262,96020,566,49797%Phase 534,123,30535,315,375103%Total66,076,76866,582,317101%35,680,91136,012,154101%Independent assessment96% (Independent survey of phase 5 by education department with WHO assistance)92% (RCA by independent local and international monitors)

  • Few facts & figures

    PakistanBangladeshSkilled person41,98652,397Non-skilled person/volunteer64,733762,1921st line supervisors6,9949,505Vaccine (doses)81 million44 millionAD syringes81 million44 millionReconstitution syringes8.1 million4.4 millionSafety boxes890,000484,000Campaign duration2 to 2 weeks3 weeksActual campaign working days15 days (18 days in ph 1)12 daysAverage cost per child (approx.)US$ 0.55US$ 0.38

  • Political commitment & supportPolitical commitmentBangladesh: Enjoyed highest level political commitmentMulti-sectoral involvement ensuredPakistan:Phase 5 enjoyed better administrative supportLocal peoples representatives extended excellent supportActive participation and support from education department in both countries

  • Campaign preparation and microplanningBangladeshAbout 1 year uninterrupted preparationHead count done in each and every schools and community for accurate target settingRepeated revision and refinement of microplanPakistanShort time of preparation in between repeated polio campaign roundsSchool target determined by head countCommunity target set by estimation from censusMicroplan prepared just few weeks before campaign

  • Cold chainGovernment in both countries provided handsome number of additional cold chain equipments from their own resourcesIn Pakistan, additional cold chain equipments reached country during the 4th phaseShortage of power supply was a common challenge in both countries

  • Safe waste disposalSafety box was used to collect sharp waste in both campaign without any exceptionBurn and burry method was adopted in most instances in both countriesUnsupervised disposal incomplete burning during the early days of campaign

  • Routine EPI during campaignBeside measles vaccination, health facility based fixed sites provided routine EPI service daily throughout the campaign days in both countriesRoutine EPI is mostly outreach based in both countriesBangladesh: went uninterrupted according to annual microplanPakistan: inconsistent scenario

  • Supervision and monitoringLimited capacity of 1st line supervisors for providing technical support to the vaccination teamUse of common sense and pro-activeness missingRegular evening meeting was held to monitor daily progress

  • International monitorsBangladesh12 monitors during Phase 123 monitors during Phase 2Pakistan2 monitors during Phase 33 monitors during Phase 46 monitors during Phase 5Good number of well organized international monitors provide opportunity for mutual benefit

  • ChallengesInadequacy of dataNumber of schools and their students; especially non-government schools of different categories, religious schoolsAccurate targetDaily progress and vaccine stock update during campaignAEFI dataSkilled manpower and their trainingVaccination in private posh schoolsNomadic population and other high risk groupPower shortage cold chain compromised Vaccine and logistics managementWaste managementTime conflict with other priority programs

  • Lessons learned

  • PreparationAfter setting strategy, adequate time is required: at least 1 year for Data collection regarding,Effective available human resourcesCold chain inventoryExact target population in school and community by registrationSchool exam and vacation schedulePopulation distribution and its ethnic and cultural diversityLocal weather patternLocal important eventsSchedule of other important program activitiesLocal level sensitization through advocacy among service providers, clients and other stakeholders

  • StrategySchool based immunization activity is easy if teachers, guardians and authorities are taken on board in advanceOutreach center based immunization program is acceptable to the communityShifting center in a larger community rises access and acceptabilityOn average vaccinating 150 200 children daily is an easy target for a skilled vaccinator

  • Political commitment, Leadership and Team spiritHighest level political commitment makes challenges easyDynamic and effective leadership from government is crucialPolitical and top level administrative involvement may require for access to posh private schoolsTeam spirit among the partners is the essence for micromanagement

  • MicroplanningFactual microplanning is the key to successAll relevant data to be ready beforehandActual site wise targetInventory of resources,ManpowerCold chain equipmentsTransportSocial and operational mappingMicroplanning to be reviewed and refined repeatedly for fine adjustment

  • TrainingMaintaining quality and consistency is difficult in multiple tire cascade trainingUsing pool of provincial/regional master trainer may give better result

  • Supervision & monitoringMedical doctors were the best choice as 1st line supervisorResponsibleEnthusiasticEarned confidence among the team and the communityDaily evening review meeting helped inIdentification and correction of problemMonitoring performance

  • Community participationThere are high demand for vaccination among the parentsLack of awareness among community about benefits of vaccination is a false statementRefusal is not a major issue

  • Teachers and students are great partners in child healthEducation department can play a vital role in promoting child health activitiesThrough participatingCreating community awarenessBuilding trust

  • Vaccine & logistics managementSeparate logistics unit for proper vaccine and logistics managementA full time consultant may lead the unitSeparate storage facility for campaign vaccine and logisticsInstead of hiring individual transportation, transport firm with good capacity can be hiredContingency plan for on road ice pack changePre arrangement of traffic clearance at ferry terminal, city entry etc.Continuous monitoring of all transporters from a central control unit up to the terminal delivery level

  • Local initiativeInnovative idea adopted for creating public awarenessEssay competition, letter writing competition, sms competition etc. among school childrenDistributing hand note on measles campaign during polio NIDPolio vaccine was given along with measles vaccine in previously inaccessible areas

  • Social mobilization and communicationTop level advocacy for appropriate sensitizationSocial mobilization by school teachers and community/religious leaders gives good return at grass root levelMosque announcement most effectiveHouse to house visit importantSchool students: good message disseminator Scope of taking advantage of nationwide media coverage is limited in multi-phased campaignAppropriate material used in appropriate place best result

  • Selection of vaccine and syringesAvoid using vaccine from multiple manufacturer for a single phase of campaignAD syringes which are locked at 0.5 ml point are better choicePlunger stops at 0.5 ml mark. Easy to use in campaign.Plunger goes beyond 0.5 ml mark. Needs more skill for dose adjustment and prone to high vaccine wastage.

  • Recommendations for vaccine package and labelingDark color vials are preferred option than transparent vials for protection from sunlightBoth the vaccine vial and diluent ampoule label to be of similar color and graphic designSame name (either manufacturer or trade name) to be printed on both vaccine vial and diluent label using same font type and sizePacking of vaccine vial and diluent must have same number of vials and ampoules

  • Bangladesh & Pakistan both are South Asian countriesHaving almost equal population, Pakistan is about 5 times larger than Bangladesh in terms of areaBangladesh being an Unitarian country administratively divided in 6 division. Whereas Pakistan, a federal country have 4 provinces, two federally administered areas (FATA & FANA) and Ajad Jammu & Kashmir-AJK (Pakistan administered Kashmir)*Bangladesh measles campaign was held in two phases during 2005 2006Pakistan campaign was held in five phases during 2007 2008During the 3rd phase campaign in Pakistan, 12 districts in Balochistan province started one week late from the scheduled date due to inadequate preparation. The main reasons for this late initiation was a natural disaster and a unscheduled polio campaign in those districts just before the campaign.*Local disease epidemiology was not taken in to consideration in determining target age range for Pakistan campaign initiallyAfter completion of Phase 1, it was reduced to 09 months less than 13 yrs from 15 yrs. This change was made considering the followings,Limited surveillance data indicates most of the measles cases occurs during the 1st decade of lifeConsidering the endemicity of the disease in the country, there are very little chance of being unexposed to wild infection beyond 13 years of ageIn many rural areas 13+ yrs aged girl children are considered adult and its difficult to bring them to the vaccination center and vaccinate them by a male vaccinator.In case of Bangladesh, strong surveillance data helped in determining the most susceptible age group easilyIndependent assessment supports achievement of very high campaign vaccination coverage in both countries*In Bangladesh campaign, most of the skilled persons were regular EPI vaccinators or other staff who were regularly involved with EPI. In Pakistan, due to shortage of regular vaccinators other paramedical staff were involved in the campaign.In Bangladesh, non-skilled team members were mostly genuine volunteers taken from the community. In Pakistan, they were mostly health staff.Regular EPI supervisors were assigned as 1st line supervisors in Bangladesh campaign whereas, in Pakistan they were mostly medical doctors. In spite of their inexperience in field supervision deployment of medical doctors proved other advantages like quick AEFI management, confidence building among the vaccination teams and the communities, better handling of rumors and refusals etc.Though Bangladesh campaign was of total 3 weeks duration but 2 days in each week was used for routine EPI according to annual microplan. So, effective campaign days were 12 days. 1st week was used to vaccinate only in schools and remaining 2 weeks in the community outreach centers In Pakistan, the 1st phase was of continuous 18 days but during the remaining phases the main campaign was of 12 days with a 3 days follow-up to catch the missed children. However, few districts has further shortened this period considering their smaller target.Operational cost of Bangladesh campaign was far less than the Pakistan campaign. Government staff at all level were not paid any extra incentive for doing the campaign except very small refreshment and transport allowance for the vaccination team members (US$ 0.80 for skilled persons and US$ 0.33 for volunteers daily) and 1st line supervisors (US$ 0.80/daily) only. Supervision and monitoring cost for the senior government officials in their own working area were borne by regular government budget. In Pakistan campaign, the rates were about 8 to 10 times higher and senior officials were to be paid transport allowance and perdiem for supervision and monitoring from the campaign fund.*In Bangladesh, Health Minister was personally involved and owned the campaign. He participated in multiple advocacy meetings including different TV talk show on the campaign. Since one month before the campaign, the minister appeared in a live show on national TV every week taking questions from the public on different aspects of the campaign. Senior program officials (National Program Managers, DG-Health) and WHO MO-EPI was with him in the panel. In Pakistan, only during the Phase 5, the campaign got support from officials beyond the EPI program. Provincial health minister, chief secretary, health and education secretary extended their full support and cooperation during the phase 5 campaign.*With active support and participation of WHO surveillance medical officers data collection and preparation for the campaign started in Bangladesh more than one year before the actual execution of the campaign. During this time, no other activities except routine work interrupted the preparation.In Pakistan, time for preparation was short and frequently interrupted by repeated Polio campaign. Moreover, it was a challenge to change the mindset of the district teams from Polio campaign strategy to measles campaign strategy.*GoB has provided more than 550 new ILR and Freezers during the campaign from their own resourcesGoP has also provided additional 1,000 ILR, 500 Freezers and hundreds of vaccine carriers and cold boxes from their own resources. However, unfortunately these cold chain equipments in Pakistan reached the country very late (just before the Phase 4)*In Bangladesh every vaccinator conducts 2 EPI outreach sessions on two predetermined days every week. These days are fixed for an individual vaccinator but varies among different vaccinators. They prepare their EPI microplan for the whole year and its followed. During the campaign, these two days in every week was exempted from the campaign activities and the vaccinators were allowed to continue their routine EPI outreach session according to their microplan. However, the campaign microplan was prepared as such that the campaign outreach session was held in the same place just on the day before the routine EPI session. So, in those sites, any missed children had a second chance to receive the campaign dose on the next day during the routine EPI session. Vaccinators carried extra measles vaccine during the routine EPI sessions to cover such children.In Pakistan, the routine EPI outreach sessions doesnt follow such rhythmic cycle and thus the same couldnt be done. Routine EPI outreach session is also not very regular in many districts. In some districts, during campaign, on the day of routine EPI the vaccinator did both (campaign + routine EPI), in some districts extra workers (if available) were engaged to do the routine EPI and in some the routine EPI was just simply dropped.*A very well organized effort was taken by the regional office to make visit by the international monitors in both phases of Bangladesh campaign. Senior government officials of MoH and/or EPI program from 5 countries (India, Pakistan, Bhutan, Myanmar, Indonesia and Maldives) and representatives of partner organizations from other country program offices, regional offices and HQs (WHO, UNICEF, UNF, CDC, ARC). All the monitors arrived the country at the same time which is very important for proper arrangement of their briefing and field trip on the part of host country without disrupting campaign activities. Such visits helped a lot both sides for better monitoring of the campaign as well as gather valuable experiences for their own. Please note that, all the countries from which representatives visited were about to conduct their own campaign soon after and this experience helped them much in gaining experiences, new thoughts and confidence.Unfortunately though much bigger and of more number of phases, the opportunity was not materialized to its full during Pakistan campaign. Very little number of external monitors could be managed to brought in during the Pakistan campaign (government officials from 4 countries and representatives from 3 agencies). It was a missed opportunity for the Indians to experience such a huge campaign who are going to conduct their own in a similar situation along with repeated Polio campaigns.Its highly recommended to take such effort to make visits by the country program officials during any campaign whore going to conduct their own soon. Personally myself and other government colleagues from Bangladesh EPI were much benefitted by observing the Nepal campaign during the early 2005 which gave us lots of new thoughts and confidence.Visits by senior officials from partner agencies also helps in to earn attention of the senior political and government officials in the MoH to their own campaign.*For a better insight of the challenges Ill suggest to visit the Challenges section of my draft report on Pakistan Measles Campaign*For this section please go through the respective sections in the Lessons learned chapter of the draft report*Vaccinating children in their school is not only easy it also gives other advantages likeIt helps in dissemination of campaign message throughout the community without any added costHelps in removing of fear of injection among the parents in the community and building their confidence on the campaignSchool teachers are respected and trusted in the community and their positive role also helps in better acceptance of the vaccination among the community*The pictures show some examples of handbills, chits, stickers developed by districts on their own initiative and printed by sponsorship of local businessmen, public representatives etc.During Phase 5 campaign in Pakistan, different districts arranged school drama, quiz competition, essay writing and letter writing competition, painting competition among school chidren on the measles campaign as well as community meetings, cultural show etc. on their own initiatives using local sponsors.In Pakistan campaign only in NWFP province, more than 200,000 children were given OPV during measles campaign who were inaccessible during polio campaigns*About the last bullet: sometimes its found that most of the posters, banners are hanged in the health facilities and not in the streets or other public places. Using these communication materials in the health facilities during a campaign has only decorative purpose. But its more appropriate to use those in public places like tea stalls, markets etc. Even hanging on the road may not be a good choice unless near to a cross road or traffic signal. The bottom picture shows a good example of using a banner in a road side tea stall in the northern area of Pakistan. Locals were reading the banner and were discussing about it. A good way for proper message dissemination.*For one campaign or for one phase of campaign, use vaccine only from one manufacturer to avoid mixing of diluents and vaccines from different manufacturer. Its very difficult for vaccine management teams at central or provincial level to supply vaccines from different manufacturers to different districts and there is very high chance of making mistakesThere are two types of AD syringes (0.5 ml) available in the market. In one variety, the plunger is locked just at 0.5 ml mark (shown on the right of the pic) and in case of the other, the plunger goes beyond the 0.5 ml mark (left). The first variety is more convenient for use in mass campaign where large number of injections to be given with in a short period of time. With this type, the vaccinator doesnt need to be concerned about the right dose till the first 8 doses from a vial. He needs to be careful for not taking air only for last two doses. With this type, its easy to give very quick injection without compromising standards. With the 2nd variety, the vaccinator needs to adjust the dose for every shot very carefully and thus its a slow process. Moreover, the dose adjustment needs to be done keeping the needle inside the vial which needs more skill and experience. If the needle is pulled out from the vial before adjusting the dose, the excess vaccine is to be thrown out and that will lead to high vaccine wastage. *Sometimes manufacturers write the trade name of the vaccine on the vial label and manufacturers name on the diluent label. This may be very confusing for the vaccinators as they find these two are different names.In countries where English is not the primary language, vaccinators may not be able to read the manufacturers name properly on the vial and diluent ampmoule label. Its suggested that, labels of both vaccine vial and diluent ampoule should be of similar graphic design and color with the manufacturers name using same type and size of font for easy understanding of the vaccinators.Some manufacturer pack the vaccine and diluent in different size e.g. 1200 vial in a vaccine carton but 1500 ampoule in diluent carton. This cause serious problem during supply at all level. Usually packages are made in three tire and these should match exactly among vaccine and diluent package for ease of supply.*