Measles Catch-up CampaignBangladesh & Pakistan

Quamrul HasanWHO - Pakistan

Sylhet

Chittagong

Dhaka

Barisal

Rajshahi

Khulna

Phase 1 (01-18 March 07) 4 districts

Phase 2 (02-18 July 07) 6 districts

Phase 3A (20 Aug to 5 Sep 07) 28 districts

Phase 3B (27 Aug – 12 Sep 07) 12 districts

Phase 4 (12-28 Nov 07) 48 districts

Phase 5 (17 March- 02 April 08) 35 districts

Phase 1 (03-22 Sep 05) 2 districts + 1 City

Phase 2 (25 Feb-16 March 06) 62 districts + 5 City

Campaign Target & AchievementPakistan Bangladesh

Target age Phase 1: 09 months to less than 15 yrsPhase 2 to 5: 09 months to less than 13 yrs

09 months to less than 10 yrs

Phase wise target & achievement (administrative data)Target Achievement Coverage Target Achievement Coverage

Phase 1 2,571,536 2,511,837 98% 1,481,321 1,374,390 93%

Phase 2 1,219,364 1,282,232 105% 34,199,590 34,637,764 101%

Phase 3 6,890,603 6,906,376 100%

Phase 4 21,262,960 20,566,497 97%

Phase 5 34,123,305 35,315,375 103%

Total 66,076,768 66,582,317 101% 35,680,911 36,012,154 101%

Independent assessment

96% (Independent survey of phase 5 by education department with WHO assistance)

92% (RCA by independent local and international monitors)

Few facts & figuresPakistan Bangladesh

Skilled person 41,986 52,397

Non-skilled person/volunteer 64,733 762,192

1st line supervisors 6,994 9,505

Vaccine (doses) 81 million 44 million

AD syringes 81 million 44 million

Reconstitution syringes 8.1 million 4.4 million

Safety boxes 890,000 484,000

Campaign duration 2 to 2½ weeks 3 weeks

Actual campaign working days 15 days (18 days in ph 1) 12 days

Average cost per child (approx.) US$ 0.55 US$ 0.38

Political commitment & support

• Political commitment– Bangladesh:

• Enjoyed highest level political commitment

• Multi-sectoral involvement ensured

– Pakistan:• Phase 5 enjoyed better

administrative support• Local people’s representatives

extended excellent support

• Active participation and support from education department in both countries

Campaign preparation and microplanning

• Bangladesh– About 1 year uninterrupted preparation– Head count done in each and every schools and

community for accurate target setting– Repeated revision and refinement of microplan

• Pakistan– Short time of preparation in between repeated polio

campaign rounds– School target determined by head count– Community target set by estimation from census– Microplan prepared just few weeks before campaign

Cold chain

• Government in both countries provided handsome number of additional cold chain equipments from their own resources

• In Pakistan, additional cold chain equipments reached country during the 4th phase

• Shortage of power supply was a common challenge in both countries

Safe waste disposal• Safety box was used to

collect sharp waste in both campaign without any exception

• Burn and burry method was adopted in most instances in both countries

• Unsupervised disposal incomplete burning during the early days of campaign

Routine EPI during campaign

• Beside measles vaccination, health facility based fixed sites provided routine EPI service daily throughout the campaign days in both countries

• Routine EPI is mostly outreach based in both countries– Bangladesh: went uninterrupted according to

annual microplan– Pakistan: inconsistent scenario

Supervision and monitoring

• Limited capacity of 1st line supervisors for providing technical support to the vaccination team

• Use of common sense and pro-activeness missing• Regular evening meeting was held to monitor

daily progress

International monitors• Bangladesh– 12 monitors during Phase 1– 23 monitors during Phase 2

• Pakistan– 2 monitors during Phase 3– 3 monitors during Phase 4– 6 monitors during Phase 5

• Good number of well organized international monitors provide opportunity for mutual benefit

Challenges• Inadequacy of data– Number of schools and their students; especially non-

government schools of different categories, religious schools

– Accurate target– Daily progress and vaccine stock update during campaign– AEFI data

• Skilled manpower and their training• Vaccination in private posh schools• Nomadic population and other high risk group• Power shortage cold chain compromised • Vaccine and logistics management• Waste management• Time conflict with other priority programs

Lessons learned

Preparation

After 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 activities

Local level sensitization through advocacy among service providers, clients and other stakeholders

Strategy

• School based immunization activity is easy if teachers, guardians and authorities are taken on board in advance

• Outreach center based immunization program is acceptable to the community

• Shifting center in a larger community rises access and acceptability

• On average vaccinating 150 – 200 children daily is an easy target for a skilled vaccinator

Political commitment, Leadership and Team spirit

• Highest level political commitment makes challenges easy

• Dynamic and effective leadership from government is crucial

• Political and top level administrative involvement may require for access to posh private schools

• Team spirit among the partners is the essence for micromanagement

Microplanning

Factual microplanning is the key to success

All relevant data to be ready beforehandActual site wise targetInventory of resources,

ManpowerCold chain equipmentsTransport Social and operational

mappingMicroplanning to be

reviewed and refined repeatedly for fine adjustment

Training• Maintaining quality and

consistency is difficult in multiple tire cascade training

• Using pool of provincial/regional master trainer may give better result

Supervision & monitoring

Medical doctors were the best choice as 1st line supervisorResponsibleEnthusiasticEarned confidence among

the team and the community

Daily evening review meeting helped inIdentification and

correction of problemMonitoring performance

Community participation

There are high demand for vaccination among the parents

Lack of awareness among community about benefits of vaccination is a false statement

Refusal is not a major issue

Teachers and students are great partners in child health

• Education department can play a vital role in promoting child health activities– Through participating– Creating community

awareness– Building trust

Vaccine & logistics management• Separate logistics unit for proper vaccine and logistics

management• A full time consultant may lead the unit• Separate storage facility for campaign vaccine and

logistics• Instead of hiring individual transportation, transport

firm with good capacity can be hired• Contingency plan for on road ice pack change• Pre 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 children

Distributing hand note on measles campaign during polio NID

Polio vaccine was given along with measles vaccine in previously inaccessible areas

Social mobilization and communication Top level advocacy for appropriate

sensitization Social mobilization by school teachers

and community/religious leaders gives good return at grass root level

Mosque announcement most effective

House to house visit important School students: good message

disseminator Scope of taking advantage of

nationwide media coverage is limited in multi-phased campaign

Appropriate material used in appropriate place best result

Selection of vaccine and syringes

• Avoid using vaccine from multiple manufacturer for a single phase of campaign

• AD syringes which are locked at 0.5 ml point are better choice

Plunger 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 labeling

• Dark color vials are preferred option than transparent vials for protection from sunlight

• Both the vaccine vial and diluent ampoule label to be of similar color and graphic design

• Same name (either manufacturer or trade name) to be printed on both vaccine vial and diluent label using same font type and size

• Packing of vaccine vial and diluent must have same number of vials and ampoules