National Measles and Rubella Immunization

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					                        Report on
        National Measles and Rubella Immunization
                        Campaign

                                Republic of Maldives

                                          2005-2006




                            Dr Ananda Amarasinghe
                                  STC – WHO
                                 January 2006




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
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                                       Table of Contents
Contents                                                                        Page #

Acronyms

Executive Summery

1.0 Introduction
   1.1 Background
   1.2 Campaign Rationale

2.0 Pre -Campaign Activities
   2.1 Planning and Micro-planning
   2.2 Training
   2.3 Provision of supplies and logistics
   2.4 Advocacy and Social Mobilization
   2.5 Pre campaign activity i n Male
   2.6 Pre -campaign Assessment

3.0 Implementing the Campaign
  3.1 Provision of Supplies
  3.2 Launching of the campaign
  3.3 Conducting vaccination sessions
  3.4 Management of Data
  3.5 Supervision and Monitoring
  3.6 Advocacy and Social Mobilization

4.0 Programme Evaluation
  4.1 Rapid Convenience Assessment
  4.2 Programme Achievement

5.0 Post Campaign Activities
   5.1 Mop-up Campaign
   5.2 Disease Surveillance and Guidelines
  5.3 Strengthening EPI Activities

6.0 Recommendations

Annexure




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
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                                            ACRONYMS

AEFI              : Adverse Events Following Immunization
AD                : Auto Disable
CHS               : Community Health Supervisor
CHW               : Community Health Worker
CIP               : Catch-up Immunization Programme
CRS               : Congenital Rubella Syndrome
DPH               : Department of Public Health
EPI               : Expanded Program on Immunization
IGMH              : Indira Ghandi Memorial Hospital
IM                : Intramascular
IPC               : Interpersonal Communication
MMR               : Measles-Mumps-Rubella
MO                : Medical Officer
MoH               : Ministry of Health
MR                : Measles-Rubella
NGO               : Non Government Organization
OPD               : Outpatient Department
PAHO              : Pan American Health Organization
RCA               : Rapid Convenience Assessment
SEARO             : South East Asian Regional Office
STC               : Short Term Consultant
UNICEF            : United Nations Children Fund
VPD               : Vaccine Preventable Disease
WHO               : World Health Organization




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
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                                   Executive Summary

The National Measles-Rubella catch-up immunization campaign in the
Republic of Maldives was launched on the 4th December 2005 to be
completed on t  he 4th January 2006, as a part of the global effort in
prevention and control of measles and rubella in countries, regions and
worldwide . Target group of this campaign was all males in the age group
of 6-25 years and females in the age group of 6-35 years, irrespective of
their previous measles and rubella vaccination status or illnesses. An
estimated number of 145,000 eligible population w   ere targeted during
this campaign to provide MR immunization.

                                                           e
Pre -campaign, campaign and post campaign activities wer conducted
according to micro planning. MR immunization clinics were conducted at
the fixed sites and outreach settings, ensuring that the routine
immunization was uninterrupted. The recommended immunization team
was consisted of a Me dical Officer, Nurse, Community Health Supervisor,
Community Health Worker and volunteers. Strong vigilance ensured the
cold chain maintenance to ensure vaccine quality. All clinic sites were
provided with emergency kit to ensure management in any emergency. In
Male, ‘Mini Emergency Unit’ was established at each clinic site with all
basic equipments. Weekly ‘Tele Video Conference’ was held to discuss
and review the technical and managerial problems with the Atoll
managers and Medical Staff.

The WHO has provided the technical and financial support to develop
highly attractive and informative IEC materials leading to public
motivation and support towards the campaign. It is undoubtedly a good
investment by the WHO despite the high costs.

Advocacy and social mobilization were continued during the campaign.
All electronic and printed media in Maldives have given wide publicity
through-out the campaign period. SMS based awareness programme
were carried out with the support of private mobile phone companies,
particularly to motivate adolescents and young adults. Scouts and
Guides have done a house to house visit awareness campaign, which no
doubt is one of the most powerful advocacy strategies in the MR
campaign, particularly in Male.

The vaccination team supervisors and Atoll managers monitored the
campaign on regular basis. In order to ensure the quality of the
campaign, a checklist based supervisory tool was used and evaluate the
campaign activities and implementation process. In addition, a national
team from the DPH and independent observers from partner agencies




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
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(WHO and UNICEF) visited the Atolls and Islands and monitored the
campaign activities.

                                                 as
20 household Rapid Convenience Assessment w conducted covering
1060 households in the third week of the programme covering at least
three islands from each Atoll. The objective of RCA is to monitor and
evaluate the progress of the MR campaign and to make necessary
recommendations to continue the MR programme to achieve its set
objectives. According to the RCA, reported coverage w    as 77%. RCA
revealed that the main source of information for the public is the
Television (81%)

During the MR campaign, a “Supply Audit’ was conducte d to ensure the
smooth distribution of supplies from central to the Atolls. Except in a few
places, there were no significant issues in provision of supplies reported
or observed. However, a few short comings were observed at the Central
Supply Unit in the monitoring of distribution of supplies.

The overall coverage of MR catch-up immunization is 82%. The coverage
is ranging from the lowest of 67% in Alif Dhal Atoll to the highest of
100% in Baa and Vaavu Atolls. The coverage for Male is 68%. The overall
coverage of age groups is: 83% for 6-14 year males, 84% for 6-14 year
females, 6 8% for 15-24 year males and 75% among the 25-35 year
groups. The vaccine wastage rate is around 5% which is impressive. The
reported AEFI incidence is 11.4/1,000 vaccinees. However under
reporting of AEFI is not ruled out. Only two serious AEFI have been
reported, but both recovere d completely.

Mop up campaign will be carried out in all Islands / Atolls, where MR
campaign coverage is below 95%. House to house mop-up is not practical
and not cost effective in Maldives, hence institution based mop-up will be
the choice. All those who have missed the MR vaccination should be the
target. In addition, foreign employees in eligible age groups need to be
vaccinated.
It is recommended that CRS to be ma de a notifiable disease. Case based
surveillance is proposed for all measles, rubella and CRS cases. All
reported cases of measles, rubella and CRS need a laboratory
confirmation at Government cost. Maldives should incorporate rubella-
containing vaccine (MR or MMR) into childhood vaccination programmes,
both as part of routine childhood immunization at 18 months or at 3
years, and as part of the follow-up campaigns. MR campaign did not
cover children below 6 years of age and these children therefore need to
be covered with MR or MMR. It is recommended to conduct National
/Regional / Atoll level EPI review meetings regularly, preferably quarterly
or at least once a year.



Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
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                                   1.0 INTRODUCTION

1.1 BACKGROUND

Measles is a highly infectious disease, which primarily affects the
respiratory tract. It is an important childhood disease in Maldives. After
the introduction of measles immunization to the EPI in 1985, the
incidence of measles gradually decreased. However, Maldives has
experienced several outbreaks of measles. The largest outbreak occurred
in 1994 with 3,070 reported cases. Another outbreak of measles was
reported in the year 2002 with 924 cases. During the current year 2005
                                                           .
an outbreak occurred with 1395 cases being notified Measles is a
notifiable disease in Maldives.

The objective of the measles control programme in Maldives is to re duce
mortality   by     95%    and    to    reduce    morbidity    by     90%
due to measles. The present objective is a reduction in incidence and
mortality due to measles as a major step to the global eradication of the
disease and prevention of outbreaks.

Rubella is a self-limited febrile rash illness with few complications.
However, if a woman contracts the rubella infection in the early stages of
her pregnancy, the rubella virus has devastating consequences and may
cause a syndrome known as CRS. Rubella is a public health concern in
Maldives. A retrospective review of the disease burden due to rubella and
congenital rubella syndrome was carried out in Maldives in 2003.
According to the available data the mean age of acute rubella infection is
shifted to 20-25 years. Retrospective analysis has estimated CRS
incidence of 0.2 /1000 live births in endemic periods and 1-4 CRS cases
per1000 live births during the epidemics. This ranges 1-22 cases of CRS
in Maldives. The results of the review indicated that out of all the people
living with a disability in the country (obtained from the study on
disability burden of Maldives), 53% of the men and 47% of the women
have disabilities that are compatible with CRS complications.

An outbreak of rubella was reported in the year 2000. In that year 1650
cases of the disease were reported, with an incidence of 568 per 100,000
population. Rubella is a notifiable disease in Maldives, but not the CRS.

The objective of the rubella immunization programme of the country is to
control morbidity and mortality due to congenital rubella syndrome and
morbidity due to rubella infection (in children and adults ). Considering
the present rubella epidemiology and burden in the country, the Ministry
of Health has decided that the current effort in measles control should be




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
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used as an opportunity to pursue control of rubella through MR
vaccination.

A safe and effective bivalent vaccine is available for measles and rubella.
The WHO and UNICEF adopted a joint strategic plan for global measles
mortality reduction in 2001, which was endorsed by the World Health
Assembly in 2003. In the same year WHO-SEARO developed a regional
strategic plan based on these global strategies. WHO also recommends a
rubella immunization for countries that have demonstrated a disease
burden due to rubella.

Government of Maldives has endorsed a national plan of action for
rubella/CRS syndrome and measles elimination. Conducting measles
rubella campaign for children 6-14 years, female 15-35 years and males
15-25 years is a key component of this plan. This would be followed by
the introduction of Measles- Mumps - Rubella vaccine into the national
EPI programme in the coming years.


1.2 RATIONALE FOR THE CAMPAIGN

Countries that have offered only one opportunity for measles vaccination
through routine services experienced frequent measles outbreaks, even
after achieving high (>90%) coverage. Often these outbreaks affected
older children. Countries providing two opportunities for measles
vaccination have experienced a sharp drop in the number of cases and
an even greater drop in the number of deaths. These reductions have
occurred after high-quality immunization campaigns with >95%
coverage.

In Maldives, measles vaccination coverage has reached over 95% through
routine services.
Year          1995 1996 1997 1998 1999 2000 2001 2002 2003

Measles
Coverage %          94        95       96        98           99   99      98      97       96
Source: The Maldives Heal th Report 2004, Ministry of Health

Measles vaccine is 85% effective when given at 9 months of age. As a
result there is accumulation of susceptible children over time, leading to
periodic measles outbreaks. To supplement routine services, a catch-up
campaign is an effective way to reach children who have never received
the routine dose and those who did not develop immunity after first dose
due to primary or secondary immunization failures. To prevent measles
outbreaks, it is important to maintain high population immunity. A
second opportunity for measles immunization while keeping routine


Measles Rubella Immunization Campaign, Maldives, 2005-2006.        Dr Ananda Amarasinghe WHO/STC
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immunization coverage for infants high will reduce the proportion of
susceptible children and prevent measles outbreaks.

Rubella vaccine has more than 95% sero-conversion even given at 9
months. Accordingly a single dose of rubella vaccine will prevent women
in child bearing age getting rubella infection when they are pregnant.
Eventual elimination of rubella will be ensured, if rubella vaccine is given
to children and susce ptible males. The review study done in 2003
recommended mass vaccination targeting 15-35 age groups females and
a 50% immediate decline in CRS is expected. It is estimated that the cost
of eliminating CRS is 7% of the total cost of health and rehabilitation
services for children with CRS. It is expected that 8 cases of CRS
annually and their life time economic burden is around one million US$
to the Government of Maldives.

With these facts, the Government of Maldives has decided to conduct
measles rubella campaign in December 2005. The objective of the
campaign is to achieve at least 95% coverage to develop high population
immunity against measles and rubella.

In order to reach the goal of measles mortality reduction, campaign
activities should target the persons at highest risk of contracting the
disease. National surveillance data of 2002 and 2005 outbreaks indicates
that over 93% of measles cases occurred in people above 5 years of age
and around 82% are in the age of 5- 25 years. The retrospective review of
rubella indicated that nearly 50% of acute rubella infections occurred in
women of child-bearing age . Therefore all children from 6-14 years,
female in child bearing age of 15-34 years and male from 15-24 years are
targeted irrespective of their previous measles rubella vaccination status
or illness. As such approximately 145,000 people of this age group is
given an additional opportunity to be vaccinated against measles and
rubella . The measles rubella campaign was conducted as a rolling
campaign in islands over 5 weeks from 4 December 2005 to 04 January
2006.




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
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                        2.0 PRE-CAMPAIGN ACTIVITIES
To successfully implement a mass vaccination campaign, the following
are essential activities; information based decision making, fostering
high-level political commitment, participation of medical and professional
associations     during   the   campaign,    intersectorial   cooperation,
involvement and commitment of health workers, capacity-building,
enhancement of human resource performance s, high community
participation, innovative social mobilization strategies, powerful and
properly tailored communication messages and support of donor
agencies.



2.1 PLANNING AND MICRO PLANNING

MR campaign planning activities were begun in early 2005. First, the
DPH outlined the MR campaign strategies and activities to be followed to
achieve the MR CIP objectives. Special attention was given to the specific
issues of the country (post tsunami health impact), availability of
resources, and possibility of donor support. Decisions on the target
population, campaign time period, possibility of phasing the programme
were based on the available information and the past experiences of the
country in mass immunization programmes. American Red Cross, WHO
and UNICEF were requested for possible financial and technical support.

Forming National and Atoll MR CIP coordination committees are
important to ensure the successful implementation of a national MR CIP
in the country. Coordination with Public health staff, Hospital health
staff and other sectors such as Atoll Administrators, Ministry of
Education, and Ministry of Fisheries is essential at National, Regional
and Atoll levels to implement the campaign. At national level a MR
campaign operational committee was formed and this was chaired by the
Hon. Deputy Minister of Health. This was helpful to address many of the
practical issues in pre campaign period, particularly in Male. However,
this committee did not represent any other ministries, which is a missed
opportunity to achieve the programme objectives in more cost benefit and
efficient ways.

Micro planning is crucial to ensure each and every aspect of the
campaign. Estimating target populations, identifying available resources,
conducting need assessments, advocacy and social mobilization in field
setting and, training are some of the key components in micro planning.
Micro planning was first done at island level and based on that
information Atoll level plan was developed.



Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
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Micro planning was started with the training of Atoll staff on how to
develop micro plans. Atoll level micro planning and training workshop
has been conducted by the DPH with the assistance of a SEARO
consultant. Island micro planning meetings were conducted for those in-
charges of health posts/health centre s. With this training exposure,
Islands and Atoll had developed the coordinated micro plan and the
following outputs are expected:
• Determination of the number of vaccination sites
• A plan for special working forces such as fishermen and, resort
    workers
• A list of vaccinators        and plan vaccinators to sites during the
    campaign
• Determination of the actual number of volunteers needed and list of
    their names
• Identifying first line supervisors (with designations)
• Schedule of field health staff and volunteers training with date, time
    and venue at ward level
• Estimation of vaccine and other logistics and a plan for distribution of
    vaccines and other logistics
• A waste management plan
• An AEFI management plan including primary care and referral
    specifying responsibilities of persons and facilities
• A plan for social mobilization and advocacy

However, some of the atolls didn’t develop the comprehensive micro
plans, as it is expected during the micro planning training sessions. The
most likely reasons for these shortcomings are; the persons trained
during the micro planning training by DPH did not actively involve in the
atoll micro planning, lack of training of island public health staff in
developing micro plans, dependency on Atoll/Island office population
statistics , which are not updated etc.,

Identifying Target Population

This is of utmost importance , as all estimates and planning are focused
to cover the target population. The birth registry available at Atoll/Island
office was made use of to identify and estimate the target population by
islands and wards. Target group was listed according to the Age (Male 6-
14 years, Male 15-25 years, Females 6-14 years & females 15-35 years],
Sex and by residence . In practice it may not be realistic to get a 100%
complete list of a ll inhabitants as some proportion of this target
population is moving from place to place , time to time. However, making
the proxy list of target population is expected. But it was revealed that



Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
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some atolls had failed to do so resulting in an over estimati on of the
target population.


Identifying Vaccination Sites

Immunization clinics were planne d to be conducte d at fixed sites at
hospitals / health posts and out reach by Atoll mobile teams. Out reach
clinic centre s are identified, listed and mapped. The accessibility of the
                                               .
target group to these centres was highlighted Each island had identifi e d
one or more clinic sites to cover one or more wards at a time.


Vaccination Team

The vaccination team comprised of 1 Medical Officer, 1-2 Nurses, I CHS,
2 CHW and Volunteers. It is recommended that the out reach mobile
teams visited the hardly accessible islands always accompanied by a
Medical Officer. This is of utmost importance in managing acute AEFI
events.


Estimating supplies

Based on the target population in Atolls, the estimates for vaccines,
injection safety items (AD syringes, Reconstitution syringes, Safety
boxes], cold chin equipment and other logistics required were prepared.

(a) Amount of MR vaccine required = Number of Target Population x 1.2
(Wastage factor]
[b) Amount of 0.5ml AD syringes required = Number of Target
Population x 1.1 (Wastage factor]
(c) Amount of 5ml Reconstitution syringes required = Number of Target
Population x 1.1 (Wastage factor] / 10 (MR vial is with 10 doses]
(d) Amount of Safety Boxes required =[ Number of AD syringes +
Number of Reconstitution Syringes ] /100 x 1.1 (Wastage factor] = [ b +
c ] / 100 x 1.1


Cold Chain

Estimates for the cold chain equipments [Igloo, vaccine carriers, ice
packs are based on the numbers of fixed immunization sites and mobile
teams. The requirement of cold chain items for the out reach clinics are
based on the number of mobile teams, but NOT the numbers of expected



Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
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out reach clinic sites as one or few mobile teams cover all out reach
clinics.

Cold chain inventory was taken during the micro planning, indicating
functional and non-functional equipment with regard to numbers,
locations, gaps and requesting the need to cater to the MR campaign.
The cold chain space required to keep MR vaccine at Atolls and Islands is
estimated, considering enough space to be made available for the supply
of vaccines for routine immunization. The micro plan included the
contingency plan in case of longer power failures that could threaten the
cold chai n. This exercise is certainly useful in order to improve the cold
chain facilities in the country, particularly in routine EPI activities.


Waste disposal

The Atoll plan for disposing filled safety boxes and other wastes include d
the following information: Location or places where filled safety boxes are
stored before disposal, Identification of persons responsible for waste
disposal, Identification of waste disposal sites, mode of transportation of
filled safety boxes from each vaccination post and method and frequency
of disposal of all wastes.


AEFI Management

MR Vaccine is safe and effective. But, no vaccine is perfectly safe and
adverse events can occur following immunization, and the probability of
occurrence of AEFI is high during a mass campaign. In addition to the
vaccines themselves, the process of immunization is a potential source of
adverse events. Therefore micro plan included the field case management
and plan for referral of severe cases to the hospitals.


Reviewing Micro Plans

The CHW at the island prepared the micro plan using the standard
formats developed by the DPH. The CHS at the Atolls consolidated the
estimates received from islands and submitted the total requirement of
Atoll to the DPH.

DPH reviewed the micro plans received from all Atolls. Some adjustments
were made in the estimates, as the available statistics at the MoH have
shown some discrepancies with the Atoll figures. These estimates were
finalized with the Atolls and according to the final estimate, the
distribution plan for the provision of supplies (vaccines, injection safety


Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
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items, cold chain equipment, and stationery) was developed. Most of the
micro plans of the Atolls have been completed timely and were
satisfactory. The DPH has paid special attention to the Atolls, where the
micro plan needed some improvement.



2.2 PROVISION OF SUPPLIES AND LOGISTICS

The success of the campaign depends on sound advance planning for
vaccine and logistic supply especially at the Atoll and Island levels. This
requires: ordering correct vaccine and logistics quantities using the best
data available and by using standard formula, ensuring that the MR
vaccine vials and diluents from same manufacturer and within expiry
date are distributed together, developing a distribution plan that
specifies when and how supplies are to be transferred to Atolls, Islands
and vaccination sites AND paying particular attention to logistics
requirements for hard-to-reach Atolls and islands, particularly
considering the unpredictable weather which affe cts the transport service

Based on the estimates and requests received from Atolls, DPH prepared
the distribution plan for vaccines, injection safety items and other
supplies to the Atolls. Vaccines and injection safety items were sent to all
Atolls in advance and there was no complaint on any shortage from the
Atolls or Islands.

However a significant delay in the distribution of forms and registers to
the Atolls and Islands was noted. DPH with the support of WHO/STC
developed all forms and registers required for MR campaign monitoring
well in advance. However there was a delay in printing and this was
worsening with the limited human resources at the central supply unit,
where dispatch of these supplies to the Atolls was taking place. As a
result, some of the Atolls had received IEC materials only after
commencement of the programme, despite the distribution of IEC was
handed over to the private sector.


2.3 TRAINING

The success of a programme of this nature largely depends on the
performances of the health staff. Therefore the training is an essential
component to ensure good performances by the staff.
The following areas are to be covered in training of the MR Campaign;
   • Programme objective and rationale
   • Micro planning



Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
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    •    MR vaccine
    •    Conducting immunizati on sessions
    •    Cold chain maintenance
    •    Injection safety and waste management
    •    AEFI and management
    •    Record keeping and reporting
    •    Advocacy and communication

Guideline on MR campaign

To facilitate the micro planning and training activities, a comprehensive
guideline was developed by the WHO/STC. Rationale for MR campaign,
planning, training, advocacy, conducting immunization clinics, cold
chain, AEFI and their management, injection safety and waste
management, reporting system, supervision and monitoring, post
campaign activities and mop up are described in this guideline. This is a
self learning material to all health staff to get prepare for the MR
campaign and provide the technical information on MR vaccines and
other areas, such as AEFI etc.,

In addition to the guideline, a Power point presentation was available as
a training material for the health staff. The DPH sent printed and
electronic copies of these training materials to all Atoll public health
units by post and e -mail.

All these guidelines and forms are available in the web site of the MoH.
(www. dph. gov.mv and www.health.gov.mv)


National level Training

DPH plan to conduct a seri es of training sessions for Medical Officers
and Nurses in Male Atoll and for the Hospital managers and CHS from
other Atolls. However this had not materialized as planned. Hence only a
series of informal meetings with respective Hospital managers, CHS and
CHW were undertaken by the DPH. During this informal training,
particular attention was given to the role and responsibilities of all
concerned persons.

The reasons are the limited time factor and inability to get the Atoll staff
to Male due to the tight scheduling of other programme activities. If
better coordination among the different Units in MoH and DPH had been
established, this would have been done more efficiently and effectively.




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
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2.4 ADVOCACY AND SOCIAL MOBILIZATION                                                                 Deleted: ¶
                                                                                                     ¶

Through the national advocacy meeting all-important stakeholders from
different sections within the MoH and outside the MoH, such as Atoll
authorities, Ministry of Education and, Ministry of Fisheries had to be
provided with information on the MR campaign that helped to gain their
support and commitment. But a few high level advocacy activities were
noticed during the pre campaign peri od.

Advocacy meetings with Medical Specialists

Paediatricians and Physicians’ support is crucial in a MR campaign for
gaining trust on the programme, increase coverage and management of
AEFI. Medical specialists were concerned about the contingency plan on
managing emergencies and agreed to the list of basic life saving
emergency items for the vaccination teams. There was significant
pressure from the medical specialists in Male to introduce MMR,
particularly considering the ongoing outbreak of mumps in the country.
After the discussions and review of the situation with the programme
objectives by the MoH and medical specialists, it was agreed that the MR
campaign should be continued as planned, but the need of introduction
of MMR into the routine EPI in coming years wa s stressed.

Advocacy meeting                  with      the      other    Government       Sectors         and
Community Sectors

The Atoll chief, Island chief, and all other government and, non-
governmental organizations related with EPI activities, representatives of
different social and religious groups and voluntary organizations were
kept informed on the MR campaign by the Atoll Public Health Authorities
and ensured their fullest support and commitment for the campaign.

Advocacy meeting with Media
Advocacy with the media has two major concerns: Firstly, in a mass
campaign with injectable antigen for a large proportion of population, it
is expected that some would develop AEFI of different severity. A single
negative report in the media could ruin the campaign. Therefore it is
important to make the media aware and understand of the campaign’s
importance and the detrimental effect of any negative news.

Secondly, Adolescents and adults are difficult to reach with mass
vaccination campaigns possibly because vaccination usually is not
considered part of their health care. Therefore the benefit of the
programme, particularly to the adolescent will be emphasized during
these awareness programmes.



Measles Rubella Immunization Campaign, Maldives, 2005-2006.    Dr Ananda Amarasinghe WHO/STC
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The attractive electronic TV spots and colourful posters with the popular
personalities invariably had a booster impact on advocacy. A press
conference and a media seminar were conducted with the participation of
high officials from the Ministry of Health and medical specialists.



SOCIAL MOBILIZATION

Starting two weeks prior to the actual campaign, island based awareness
programme was launched. All target population was requested to come
on a specific date and to a specific vaccination site.

Steps were taken on national level for publicity in favour of the campaign
in all-national and important local newspapers. Prominent medical
specialists were interviewed in electronic media regarding the campaign
and thereby building up public confidence.

Health education section developed posters, leaflets, banner, generic
folders, brochures, fact sheets etc., The messages were about measles
and rubella/CRS, availability of safe and effective vaccine for both
diseases, the government decision to conduct the campaign and dates for
                                                                   h
the campaign. These IEC materials were highly attractive, despite t eir
high cost. WHO has provided the technical and financial support to
develop these IEC materials, which surely was a useful investment.

The support from the scouts before and during the campaign in Male is a
classical example of the successful advocacy and social mobilization in
the MR campaign. Invitation cards were distributed by the scouts for
every target household in Male, indicating name of the person with
specific date and venue of vaccination. It is the grater support of the
scouts, which had motivated the public by various means.



2.6 PRE CAMPAIGN ACTIVITIES IN MALE

Male is the administrative and commercial centre of the country with the
highest population density. The total population in Male is around
75,000. The MR campaign target population is around 40,000. This is a
highly mixed group with a high moving population. A large number of
residential employees from overseas are working in Male. During the
micro planning in Male, all above factors were considered.




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
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Male is divided into four wards and one out reach clinic was set up in
each ward. IGMH functioned as a referral centre for any emergency.

A list of all households with the target population was prepared by the
wards and invitation letters were hand delivered by the Scouts. Each
household was given a fixed date and place for MR immunization.
However, who ever had any difficulties to come for vaccination on the
scheduled day, they were given opportunity to get the vaccination on any
other date .

Except the Medical officers and Nurses the other vaccination team
members were identified by names well in advance and given training.
However, there was a substantial delay in identifying the MO and Nurses
due to the limited number of available MOO and Nurses at the IGMH. It
is clear that the allocation of a group of MOO and Nurses through out
the campaign period (nearly 30 days) is a challenge, as the routine
medical care service at the IGMH has to be maintained. Though the CHW
are trained to administer vaccines, they         are not considered as
designated vaccinators during the MR campaign in Male.




2.7 PRE-CAMPAIGN ASSESSMENT

Supervision of the measles campaign started well before the actual
campaign began. This ensure d that required pre -campaign activities are
accomplished including social mobilization, training activities,
maintenance of cold chain, and distribution of vaccine and logistics
before the campaign. Two weeks before the campaign, hospital managers
and CHS from the Atoll level assessed preparations using a structured
checklist.(Annex I)No significant failure in preparation has been reported
from any of the Atoll.




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              19
                    3.0 IMPLEMENTING THE CAMPAIGN                                                  Deleted: ¶
                                                                                                   ¶
                                                                                                   ¶
In the present context, implementation refers to the provision of vaccine
and supplies, launching of the campaign, the activities at immunization
posts, supervision and monitoring.


3.1 PRIOVISION OF SUPPLIES

According to the initial estimates made by the Atolls, the required
amount of MR vaccine was over 250,000 doses, which certainly was an
overestimate. Therefore, DPH had adjusted this number based on the
best available statistics. Based on the revised micro plan estimation,
vaccines and other supplies were transported from the central to the
Atolls. During the campaign, DPH closely monitored the vaccine usage
and immunizati on coverage of those Atolls and it was revealed that
except for four Atolls the amount of vaccine allocated was sufficient.
However, some of the Atolls had requested for more vaccines, as
originally requested. Additional amount of vaccines for those Atolls were
sent during the campaign, and this has caused no disturbance to the
campaign in these Atolls. Injection safety items, stationery, forms and
registers were sent as requested by the Atolls. The distribution of the
vaccines and other supplies to the Is land is dependent on the availability
of medical institutions in the island. Otherwise vaccine and other
supplies are distributed only on the day of the campaign to the
vaccination sites according to clinical session schedules.

During the MR campaign, a “Supply Audit’ was conducted by the DPH to
ensure the smooth distribution of supplies from the central to the Atolls.
Except in a few places, there were no significant issues in the provision
of supplies reported or observed. The audit revealed a few shortcomings
at the central supply unit in monitoring the distribution of supplies to
the Atoll.


3.2 LAUNCHING OF THE CAMPAIGN

The official launching of the MR campaign was held on 4 December
                                                          th

2005 in Male. His Excellency the President, Honorable Minister of
Health, and Honorable Deputy Minister of Health participated into the
inauguration ceremony at the IGMH, indicating the highest government
and political commitment towards the MR programme. Officials of the
MoH and International agencies such as WHO, UNICEF, UNDPA, ARC
representatives were also present at the ceremony. This colourful




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              20
launching ceremony has given an encouraging symbolic support towards
the positive public response to the programme.


3.3. CONDUCTING THE IMMUNIZATION SESSIONS

Scheduling of Vaccination Sessions

Proper scheduling of vaccine sessions is essential if MR CIP has to be
successful. Vaccination sessions had to be on days and at times and
places which are convenient for the target population. Also, the sessions
were held frequently enough so that the number of persons to each
session was not so large facilitating the wait for a minimum short period.
The sessions were held the minimum of 6 hours per day and 6 days per
week.

Those missed or left out during scheduled clinic sessions had the
opportunity to be vaccinated at fixed sites that functioned throughout
the campaign period or an additional session was conducted to complete
the target population. In some islands, the teams had conducted
additional clinic sessions at night, particularly targeting the fishermen.

All hospitals, Health Centers, Health Posts and Family Health Sections
displayed MR CIP session schedules. This made the public aware to
when and where to visit for vaccination.


Vaccination Sites

During the micro planning and training, it was highlighted to identify
suitable sites with a large enough space and facilities for the conducting
a vaccination clinic. Special attention was given organi zing the
vaccination station that ensures smooth clinic functions. Areas for
registration, screening, vaccination and observation of adverse events
were to be available. It was stressed that the privacy of the vaccinee to be
maintained, particularly during the vaccination. All these were planned
in such a way, to ensure the quality of the service.


Registration

The DPH developed a MR Catch-up Immunization Register to keep all
information of vaccinees.(Annex II) Each vaccination team/site was given
a MR registry to maintain and it would be useful in future follow -up.
After the registration each vaccinee was issued with an immunization
card.


Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              21
Screening and Counselling

Before the vaccination, each vaccine was screened for any possible
contraindication by MO, CHS or CHW using a screening protocol
                                           l
developed by the DPH. In addi tion, counseling was done to keep aware
about possible side effects and precautions to be taken after the MR
vaccination. Counselling was done by the CHW and CHS, and whenever
necessary, medical officers assisted them.

Vaccination

On an average two vaccinators were assigned to each vaccination centre.
As in routine services, only auto-disable (AD) syringes were used during
the MR campaign. All vaccines were requested to wait at least for half an
hour after administering the vaccine to observe whether any serious
AEFI is followed.


AEFI Preparation

Special priority was given to the vaccination site AEFI management
practices. All sites were provided with the emergency kits. In Male, a
‘Mini Emergency Unit’ was established at each of the clinic sites,
prov iding all facilities to handle any emergency following the MR vaccine
administration. This was very much helpful in Male, as there were a large
number of persons vaccinated. There were only two serious events
reported from Atolls, and both of them recovere d following hospitalization
without any further medical complications.


Supplies

The vaccine and other supplies were brought to the clinic site by the
team. The amount of vaccine and other supplies required was based on
the expected number to be vaccinated at the given site. Supplies that
remained unused at the end of session, including unopened vaccines
and diluents, were returned to the centre from where they were
distributed maintaining a reverse cold chain for the vaccine. Completed
and signed tally sheet and supervisor’s checklists we re also returned.
Collected safety boxes and waste bags were disposed of by pit burning.




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              22
3.4 MANAGEMENT OF DATA

Data collection forms, registers, checklists were designed, developed,
printed and distributed by the DPH.

Measles Rubella Registry                                                                           Deleted: ¶


Measles Rubella Catch up Immunization Register is a comprehensive
data base of the CIP. (Annex II]Therefore each fixed site and each mobile
team maintained a separate MR Registry. Team supervisor / CHS
monitored and ensure d that these MR registries were completed and
updated. All the MR registries would be kept at the Island Health Post /
Family Health Section or at the Atoll public health unit at the end of the
MR CIP for future information and reference.

Daily Return

Each clinic session had a separate daily return of Form MR RI (Annex
III), which consists of two parts:

Part A – Tally Sheet: This had been designed to mark each vaccinee by
the age and sex groups as coverage to be analyzed by age groups viz 6 to
14 year males and females, 15 to 25 year males and 15-35 year females.
After each immunization, CHW marked in the tally sheet. In addition
information on supplies received and used is recorded in each clinic
session. This helps to monitor the wastage of supplies. If any outside
supervisor has visited the clinic site, it has been recorded.

Part B – AEFI Information: All AEFI observed during the clinic session and
reported to the clinic site during the session have been entered in Part B.
The observed and reported A     EFI are recorded separately as it helps to
investigate AEFI programe errors.

Weekly Return

This is based on the daily returns of tally sheets (Form MR-R1) recorded
during the immunization clinics.        The data in Form MR R1 is
consolidated by Island Health Post / Family Health Section and
forwarded to the respective Atoll public Health Unit using a consolidated
return form MR R2 (Annex IV) giving some statistics on coverage and
wastage of vaccine. Each Atoll consolidate d the island data (MR R2) into
the form MR-R3 (Annex V] in triplicate. One copy was sent to the DPH,
another to Region Public Health Unit and the office copy is filed.

However, DPH ha d not received the weekly reports regularly and timely
from most of the Atolls, despite the clear instructions. Partly, this may be


Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              23
due to the lack of training on reporting practice. To overcome this issue,
DPH contacted the CHS at all Atolls on a daily basis and obtained the
necessary information by telephone .

Figure:


                          RRPORTING SYSTEM – MR CIP

  Daily Return/                                         Weekly Returns
  MR Registry

                     MR R 1      ISLAND                         ATOLL                REGION
    CLINIC                       PUBLIC                        PUBLIC                PUBLIC
                                                   MR R2
                                 HEALTH                        HEALTH                HEALTH
                                  UNIT                           UNIT                 UNIT

                                                                    MR R3


                                       MR R 4

   HOSPITALS



                                                              DPH


AEFI Surveillance Returns

AEFI surveillance is of utmost importance in mass campaigns to ensure
the early detection of AEFI cases and to take early action to minimize
AEFI and also to ensure the smooth functioning of the programme.

The AEFI surveillance on MR CIP was done in two pa rts:
(i)  Vaccination site based daily returns (MR R1) from fixed sites / out
     reach mobile teams and the weekly returns from the islands (MR
     R2-Part B) and Atolls (MR R3). The CHS at each level compiled
     these AEFI information and monitored the AEFI surveillance.
(ii) Hospital based AEFI Surveillance: Each AEFI case treated at the
     hospitals (both out patient and in patient) following the MR
     vaccination had to be reported. It is the responsibility of Medical
     Officer who is treating such patient to report. Any severe case(s) or
     any clustering of AEFI cases they should be immediately notified to




Measles Rubella Immunization Campaign, Maldives, 2005-2006.      Dr Ananda Amarasinghe WHO/STC
                                                                                                 24
       the Atoll / Region Public Health Units and who would inform the
       DPH.
It is not necessary to investigate all reported AEFI. However the following
AEFI related events should be investigated by the medical Officer from
the Region / Atoll:
    • All deaths
    • All cases requiring hospitalization
    • All medical events about which people are concerned

Investigation of these AEFI related events should be done as early as
possible (preferably within 48 hours) using a special AEFI investigation
form that has been developed for special investigation of severe AEFI
cases. (Annex VI)



3.5. SUPERVISION AND MONITORING

Monitoring is an ongoing process. It starts from planning process and
will continue until the completion of the programme. Monitoring should
be done at all levels: National, Atoll and Island.

The success of the MR campaign depends largely on the work of
motivated and hard-working front line personnel and helps identify and
solve problems before referring issues to the next management level. In
this context supportive supervision is crucial. This require ensuring good
work done by the worker, correcting technical or operational errors in a
gentle way and responding quickly if any action is needed. To monitor
and ensure high quality supportive supervision, a checklist was designed
(Annex VII) and this was used throughout the campaign at all places.

The team leader (CHS) acted as the team supervisor and ensure d vaccine
and all logistics reached the vaccination site on time; if not, arrange their
availability; ensure d the all vaccinators and volunteers are present at the
site on time; if not, informed the authority for back up; made sure that
cold chain was maintained and waste management was appropriate;
ensure d that session is held properly and crowd control adequate;
ensure d the proper and correct record keeping; ensure d return of
unopened vaccine and diluents, filled safety boxes, tally sheets and his
own check -list at the end of the day.

In Male, DPH conducted a weekly review meeting with the team leaders
to identify issues and share experiences with each other team.

In addition to the team supervisor, Atoll and national managers and
independent observers from partner agencies (WHO and UNICEF)


Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              25
monitored the campaign. To ensure the quality of the campaign, they
use d a checklist similar to that used by team supervisors. The analysis of
                                ed
the monitoring checklists help to evaluate the campaign activities and
implementation process .

Managers and observers also conducted Rapid Convenience Assessment
(RCA) using the standard form developed by DPH (Annex VIII). This is an
alternative source of information on immunization coverage, and
identified pockets of unvaccinated groups, reasons for non compliance
and help in planning of the mop-up campaign.



3.6 ADVOCACY AND SOCIAL MOBILIZATION

Advocacy was continued throughout the MR campaign period. State
Television and printed media have given the widest coverage to the
programme, highlighting various activities including programme
schedules and providing other necessary information to the public.

A ‘Tele Conference’ was held every Thursday from 8.30 – 9.30 pm by the
MoH. National level programme managers, paediatricians and WHO/STC
were in the panel to discuss and review the technical and managerial
problems with the Regions and Atolls.

Mobile phone SMS messages were sent to motivate the public during the
campaign at no cost, and with the support of two mobile phone
companies’ in the country.

In Male, other than the Scouts and Guides, support of the Ward Office
was obtained to motivate the public.




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              26
                         4.0 PROGRAMME EVALUATION

The objective of the programme evaluation is to identify achievements of
set targets of the MR campaign and to identify reasons for not reaching
the set targets. Planning of the Mop up programme will base on the
performances and achievements of the MR campaign and therefore it is
important to identify the issues raised during MR CIP. Reviewing the
performances by all levels is important to locate the issues. The RCA
reports and routing MR campaign statistics are used in evaluating the
MR campaign in Maldives.


4.1 RAPID CONVENIENCE ASSESMENT

The objective of RCA is to monitor and evaluate the progress of the MR
campaign in term of compliance, AEFI, provision of supplies and to
identify any shortcomings and to make necessary recommendations to
continue the MR programme to achieve its set objectives. During this
survey those who did not receive MR vaccination are identified and
possible reasons for non compliance were identified. This gave an
opportunity to survey teams to motivate the public towards the MR
campaign. RCA was conducte d in three days: 18, 19 & 20 December i.e,
at the beginning of the third week of the MR campaign.

During the micro planning, it is expected to cover all islands; i.e each
island to have a 20 household RCA. However, with the limited time factor
and human resources, it was later recommended to conduct at least 3
RCA to cover 3 islands per Atoll. The RCA is an independent survey to
monitor and evaluate the ongoing MR campaign. Therefore, it has to
avoid bias. It is to support the local staff to identify problems and to
rectify them. Therefore, volunteers conducted the RCA, with guidance of
Atoll and Hospital managers. In addition national level managers from
DPH and observers (WHO, UNICEF) also carried out RCA, during their
visits to the islands and Atolls. In Male 8 RCA covering 160 households
were carried out by the CHS/CHW attached to the DPH in separate
wards where the immunization was completed.

RCA was conducted only in areas where MR campaign session had
already taken place using a standard format.(Annex VIII) RCA is a 20
household survey starting from a randomly selected house. Surveyors
interviewed any available household member who could give the
necessary information. After 20 household interviews, surveyor
interviewed the vaccination team leader or any other responsible team


Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              27
member to obtained information on provision of supplies and availability
of human resources. All completed RCA reports were sent to the DPH
latest by 25th December. However, DPH had not received RCA reports
from the following atolls: Shaviyani, Raa, Faaf, and Gnaviyani.

Forty six RCAs were carried out covering 1060 households . (Note: Some
RCAs done by the national team ha d covered only 10 households due to
the limited time period and in Male 160 households were covered) The
total number of eligible target population in these 1060 households wa s
5117. Of them 3946 had received the MR vaccine, giving the high
coverage of 77%. The findings of the RCA are much closer to the MR
campaign routine statistics. The MR campaign country coverage is 82%
as given in MR campaign reports. This indicates the high validity and
possibility of generalizing the RCA findings.

Table 1: RCA - Coverage by Atolls
                                  Target Eligible
                                                                Number
            Atoll                  Population                                 Coverage (%)
                                                              Immunized
                                    surveyed
 Baa                                    67                        67                100
 Vaavu                                 209                       208                100
 Laviyani                              345                       321                 93
 Gaaf Alif                             422                       393                 93
 Gaaf Dhal                             112                       103                 92
 Noonu                                 259                       234                 90
 Laam                                  238                       211                 89
 Haa Alif                              102                        88                 86
 Kaafu                                 106                        90                 85
 Haa Dhal                              159                       131                 82
 Meemu                                 543                       454                 84
 Thaa                                  371                       288                 78
 Alif Alif                             297                       233                 78
 Seenu                                 365                       250                 68
 Male                                  862                       510                 59
 Alif Dhal                             374                       214                 57
 Dhaalu                                286                       151                 53
 Total                                5117                      3946                 77

Six Atolls had the coverage over 90%, whereas another seven Atolls had
reported a coverage of 75% - 89%. Further analysis had showed that
there was no significant difference in coverage among the different age
                                         )
and sex groups. (Table 2 and Figure 1 Females age of 6-14 years and
males in same age group had the higher coverages of 8      4% and 83%
respectively. The coverage for females in the group of 1 5-35 years was
75%. It is important to highlight, that pregnant women and females in
the first 4 months of exclusive breast feeding MR vaccine was not given.
The MR vaccine was not given to pregnant women, as recommended by


Measles Rubella Immunization Campaign, Maldives, 2005-2006.       Dr Ananda Amarasinghe WHO/STC
                                                                                                  28
the WHO. The first four months exclusive breast feeding women were not
vaccinated with MR vaccine due to practical reasons, but not for any
technical contraindication. However, these females are certainly neede d
to be vaccinated during the post campaign follow up period.


Table 2: RCA - MR Immunization coverage as % by age and sex
groups

                                                         6-14        15-35
                               6-14 Male  15-25 Male
                              Coverage in Coverage in   Female      Female
           Atoll
                                   %          %       Coverage in Coverage in
                                                           %           %
 Male                             61          54          63          60
 Haa Alif                         92          76          100         87
 Haa Dhaal                        90          52          91          80
 Shaviyani
 Noon                                93                  93         87                89
 Raa
 Baa                                100                 100         100              100
 Lhaviyani                           99                 87          95                91
 Kaaf                                81                 79          84                94
 Alif Alif                           89                 71          82                75
 Alif Dhaal                          48                 42          50                60
 Vaav                               100                 100         100               99
 Meem                                93                 71          94                78
 Faaf
 Dhaal                               58                  47         59                51
 Thaa                                89                  67         92                68
 Laam                                96                  89         92                82
 Gaaf Alif                           93                  87         97                95
 Gaaf Dhaal                          91                  92         87                97
 Gnaviyani
 Seen                                76                 48          86               65
 Total (MALDIVES)                    83                 68          84               75


The reported coverage during the RCA for Male at 15-25 years is 68%,
which is encouraging, as vaccination may not be the priority event for
them. On other hand, the large proportion of males in this age group are
working in resorts, tourist industry, fisher  ies and security forces.
Therefore, these groups have to be targeted during the mop-up
campaign.




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              29
Figure 1: RCA - MR vaccine immunization by age and sex groups


                            2000


                            1500


                            1000


                              500


                                 0
                                        6-14         15-25     6-14     15-35
                                        Male         Male     Femal     Femal

                  Target                1148          1113    1026       1830
                  Population
                  Number                 956           759     862       1369
                  Immunized



The RCA also analysed the reasons for non compliance and it was
revealed that 36% has not given any valid reason, and around 15% just
ignored the programme. (Figure 2) Around 23% are out of the islands,
but it is not clear, what amount of them is out of the country, or in other
islands. During the MR campaign, MR vaccine was given to all people,
irrespective of their residency. Therefore, being out of the island cannot
be taken as a valid reason, as these people also are in the Maldives, need
to be vaccinated. Therefore, during the mop-up campaign, it is necessary
to harness all possible efforts to cover this internally ‘migrating’                                Deleted: put
population.

At present there is an outbreak of mumps in the Maldives and MMR has
been taken by public, as advised by the clinicians. MMR is available in
the private sector since mid 1990s in Maldives. During the MR campaign,
it is recommended to give MR vaccine to all, irrespective of their MMR
vaccination status, except those who had received the MMR in 2005.
Thirteen percent (13%) has reported that they had received the MMR
during this year.




Measles Rubella Immunization Campaign, Maldives, 2005-2006.    Dr Ananda Amarasinghe WHO/STC
                                                                                               30
Figure 2: RCA - Reasons for non compliance

                                                                    Difficulti in
                                                                    Accessibility

                                              4%                    Not well

                                     5%           3%                Fear of Injection
                                                    1%
            36%                                                     Fear of AEFI
                                                       15%
                                                                    Don’t
                                                                    care/Ignorance
                                                                    MMR given
                                                   13%
                                                                    Out of the island
                          23%
                                                                    Other/Unknown



As during in any national immunization programme, MR campaign has
given special concern to the AEFI. It is strongly recommended, that all
vaccination teams to get the medical officers service. RCA revealed that
over 90% teams had the service of the Medical Officer at all the time
during the campaign showing the high preparedness to handle any acute
AEFI, which is impressive. (Figure 3) Community health supervisors and
workers (CHS / CHW) are the focal point of each team and therefore their
participation is 100%. CHS/CHW are trained for vaccine administration
and conducting routine EPI clinic sessions. However, MoH has taken a
decision to get the service of the nurses into the MR campaign, to obtain
more public confidence.

Figure 3: RCA - Availability of the service of different health staff
categories

             RCA: Availability of Health Staff
             Services, as reported by Islands -
        100%

          75%

          50%

          25%

            0%
                       Medical               Nurses             CHW           Volunteer
                       Officers
                                         Always               Some times           Never



Measles Rubella Immunization Campaign, Maldives, 2005-2006.     Dr Ananda Amarasinghe WHO/STC
                                                                                                31
The reported incidence of AEFI during the MR campaign is low (11.4 per
1,000 immunized population). The reported AEFI by age and sex groups
do not significantly differ from each other group. (Table 3)

 Table 3: RCA - Reported AEFI by Age and Sex groups
                                      Number of
                        Number
                                         AEFI                                              AEFI %
                      Immunized
                                       Reported
 6-14 Male                956             15                                                  1.6
 15-25 Male               759              4                                                  0.5
 6-14 Female              862             11                                                  1.2
 15-35 Female            1369             15                                                  1.1
 Total                   3946             45                                                  1.1


Table 4: RCA - Reported AEFI
                                    Incidence
                                    (per 1000                       9%
                                                                             7%
 Type of AEFI                      immunized)
                                                                                               37%
                                                              11%
 Faintishness                            4.3

 High fever                              2.2
 Giddiness
                                         1.8                     20%
                                                                                     16%
 Rash
                                         1.3

 Enlarged lymph node                     1.1                  Faintishness        Giidiness
                                                              High Fever          Rash
 Other                                   0.7
                                                              Enlarged lymph node Other
 Total                                  11.4

Around 37% of the reported AEFI during the RCA is syncope/faintish
attack, the incidence of which is 4.3/1000. The incidence of High fever
and rash are 2.2/1000 and 1.3/1000 respectively. The reported average
AEFI rate is much lower than the expected number of AEFI.

Further, RCA studied the logistic aspects of the programme and there is
no reported interruption of vaccines or any other supply to the Atoll or
islands.(Table 5) A few places had mentioned that the amount of supplies
they had received was inadequate and received little late. However, it had
not disturbed the smooth functioning of the programme and additional
stocks were sent to the places where the shortages were intimated.



Measles Rubella Immunization Campaign, Maldives, 2005-2006.         Dr Ananda Amarasinghe WHO/STC
                                                                                                     32
                                                                                                        Deleted: ¶
Table 5: RCA- Provision of Adequate and regular supply                                                  Deleted: ¶

                                               Regular Supply                 Adequte Supply
               Supply
                                                                   n=46 (%)
 MR Vaccine                                        43(94.5%)                     45 (97.8%)
 Diluent                                           43(94.5%)                     45 (97.8%)
 AD Syringes                                       43(94.5%)                     40(85.1%)
 Reconstitution Syringe                            43(94.5%)                      47(100%)
 Safety Boxes                                      43(94.5%)                      47(100%)
 Immunization Cards                                43(94.5%)                      47(100%)
 Stationary                                        43(94.5%)                     45 (97.8%)
 Forms                                             43(94.5%)                     44 (93.6%)



Figure 4: RCA - Source of awareness


                  Other
         Neighbour
         Volunteer
      Health staff
              Posters
     News Papers
                  Radio
        Television

                               0              25              50            75           100


RCA also collected the information on sources of awareness of the MR
campaign. Television (81%) and radio (60%) are the leading sources of
information. This surely is the result of high quality television
advertisements and other interviews and discussions telecast during the
campaign. The health staff (55%) and posters (32%) are among the other
leading sources of awareness. Though the cost of these awareness
materials and productions is high, it no doubt is a good investment
towards the successful programme achievement.




Measles Rubella Immunization Campaign, Maldives, 2005-2006.        Dr Ananda Amarasinghe WHO/STC
                                                                                                   33
4.2 PROGRAMME EVALUATION INDICATORS

Coverage

The mid year estimated population of the Maldives in 2005 is 293,000.
The target age groups represent around 55% of the total population and
therefore the estimated target population of the MR campaign is
approximately 160,000.

According to the Department of Immigration and Emigration around
12,000 Maldivians are permanently living abroad. A large number of
students are continuing their undergraduate and postgraduate studies
overseas. It is estimated that 2/3 of them, i.e. 8,000 are in the MR
campaign target age groups and not in the country and therefore
exclude d from the national estimates.

At present, there is an ongoing outbreak of mumps in the country. The
clinicians have encouraged the public to go for MMR vaccination.
According to the State Trading Organization (STO), 2350 MMR doses
were imported and sold in the year 2005.

 Year                                                          2003        2004        2005
 Amount of MMR Vaccine purchased by STO                         200         155        2350
Source: STO, Maldives

During the campaign, those who have had the MMR in 2005 (with the
written document evidence) are not vaccinated, as they have be en
already immunized. It is estimate d out of all MMR vaccine given in 2005,
at least 50% are in the MR campaign target age group. Therefore thi s
group is excluded from the estimated target group.

WHO has recommended avoiding MR vaccine for pregnant women and
therefore MR campaign exclude d them from the estimates. This is count
up to 4,000 females. (A birth cohort consist of 4500)

Once all exclusions are made, the final estimated target population for
the MR campaign is approximately 145,000. This number is again re -
checked with the atoll revision estimates.

The initial estimates sent by Atolls in the micro plan had over estimated
the target population as 185,925. This was largely due to the use of
Island / Atoll population registries, which are not updated. As such, DPH
has instructed all atolls to verify the estimates. Some Atolls had revised
their estimated population and more precise estimates were given. Atolls



Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              34
where no revision of estimates had been made, the DPH estimates have
been used as final. (Table 6).
After al these estimates, the final target estimated population was                                Deleted: ¶
rounded up as 145,000.

                                                                                                   Deleted: ¶
                                                                                                   ¶
Table 6: Population Estimates                                                                      ¶


      Atoll              Micro      Revised                      DPH             Final
                       planning   estimates by                Estimates        Estimates
                     estimates by     Atoll
                         Atolls
Haa Alif                  12,077                                8,000              8,000
Haa Dhaal                 12,189                                9,500              9,500
Shaviyani                 10,478                 7,235                             7,235
Noon                       7,234                 5,309                             5,309
Raa                       13,403                 8,318                             8,318
Baa                        5,813                 4,511                             4,511
Lhaviyani                  5,977                                4,700              4,700
Kaaf                       6,443                                5,500              5,500
Alif Alif                  3,250                 2,804                             2,804
Alif Dhaal                 5,109                 4,791                             4,791
Vaav                       1,196                  740                               740
Meem                       3,370                                2,500              2,500
Faaf                       2,729                 2,729                             2,729
Dhaal                      4,296                                2,750              2,750
Thaa                       6,970                 4,321                             4,321
Laam                       8,142                                7,000              7,000
Gaaf Alif                  7,386                 4,799                             4,799
Gaaf Dhaal                 9,678                 6,468                             6,468
Gnaviyani                  6,226                 4,272                             4,272
Seen                      13,959                                9,500              5,500
Male                      40,000                               39,250             39,250
MALDIVES                 185,925                56,297         88,700            144,997

The overall national coverage is 82%. Vaav and Baa Atolls have reported
the highest coverage of 100% and the lowest of 67% is Alif Dhal. (Table 7)
Baa has reported 103% coverage, as they have covered the resorts and
many others from the out side Atoll.

In Male , with the highest population in the country, it is estimated that
around 39,250 are to be given MR vaccine. Male has reported 74%
coverage. Achieving a high coverage in a capital city, where more


Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              35
urbanized and unstable population live is a challenge. Therefore the
reported coverage of 74% is encouraging.
                                                                                                          Deleted: ¶
                                                                                                          ¶
Table 7: MR Immunization coverage by Atolls                                                               ¶

 Atoll                       Target Population        Number Immunized             Coverage %

 Baa                                 4,511                    4635                     103
 Vaav                                 740                      739                     100
 Gaaf Alif                           4,799                    4501                      94
 Kaaf                                5,500                    5120                      93
 Lhaviyani                           4,700                    4344                      92
 Noon                                5,309                    4799                      90
 Raa                                 8,318                    7331                      88
 Meem                                2,500                    2198                      88
 Haa Dhaal                           9,500                    8307                      87
 Laam                                7,000                    6059                      87
 Alif Alif                           2,804                    2399                      86
 Thaa                                4,321                    3701                      86
 Gaaf Dhaal                          6,468                    5573                      86
 Gnaviyani                           4,272                    3579                      84
 Haa Alif                            8,000                    6545                      82
 Dhaal                               2,750                    2161                      79
 Seen                                9,500                    7388                      78
 Male                               39,250                    29020                     74
 Shaviyani                           7,235                    5298                      73
 Faaf                                2,729                    1948                      71
 Alif Dhaal                         4,791                      3232                     67
 MALDIVES                          144,997                    118877                    82

Out of 20 Atolls, six atolls (Baa, Vaav, Laviyani, Kaaf, Noon and Gaaf Alif
) have over 90% coverage. (Table 8) 45% of Atolls had reached 80% - 89%
coverage and 20% had 70% - 79% immunization coverage. These
reported coverages do not much differ from the RCA findings (Table 1).

Table 8: Atolls by MR Immunization coverage level
  MR Coverage                                       Atoll                                % as
   level (%)                                                                           number of
                                                                                      Total Atolls
                                                                                        (n=20)
 Over 90%                 Baa, Vaavu, Laviyani, Kaaf, Noon Gaaf Alif                  30% (n=6)
 80 % - 89%               Raa, Meem, Haa Alif, Haa Dhal, Alif Alif,
                          Thaa, Laam, Gaaf Dhal, Gnaviyani,                           45% (n=9)
 70% - 79%                Shaviyani, Seen , Faaf, Dhal,                               20% (n=4)


Measles Rubella Immunization Campaign, Maldives, 2005-2006.          Dr Ananda Amarasinghe WHO/STC
                                                                                                     36
 65% - 69%                Alif Dhal                                                 5% (n=1)

Adverse Events Following Immunization (AEFI)

One of the performance indicators of the MR campaign is the reported
AEFI following MR immunization. Two serious AEFI of anaphylactic
shock have been reported and detailed investigation has confirmed only
one as anaphylaxis shock. However, both cases have recovered.

Table 9: Reported AEFI following MR immunization

                Type of AEFI                               Number              Incidence Rate
                                                         Reported (%)             (per 1000
                                                                                 immunized
                                                                                 population)
Faintish attack                                               58 (23.7%)             0.5
Rash / Urticaria                                               8 (3.2%)              0.1
High Fever ( > 38 0C)                                          12 (4.9%)             0.1
Lymphadenopathy                                               29 (11.8%)             0.2
Giddiness                                                     39 (15.9%)             0.3
Anaphylaxis Shock                                              1 (0.4%)                0
Other                                                         98 (40.0%)             0.8
Total                                                         245 (100%)             2.1

The commonly reported AEFI is the faintish attack (23.7%). The presence
of a Medical Officer in each vaccination team is a bonus in the Maldives
MR campaign. They have managed all these faintish attacks and also
have reported anaphylactic shock without creating any public panic and
enhancing compliance.

The other reported AEFI are rash (3.2%), High fever (4.9%), and lymph-
adenopathy (11.8%) and Giddiness (15.9%). The reported numbers are
well below the expected numbers and RCA findings (Table 4), and
therefore the high possibility of unde r reporting is not ruled out.

The most important aspect of these AEFI is that none of the reported
AEFI is not due to programme errors . This indicates the ensured high
quality of the programme.

Pregnancy and administration of MR Vaccine
Administration of MR vaccine to pregnant women has been reported
during the campaign. Clear instruction s has been given to the
vaccination teams to avoid MR vaccination on pregnant women, and
need for good screening was stressed. All awareness programmes had
given sufficient information to the public that MR vaccine will not be


Measles Rubella Immunization Campaign, Maldives, 2005-2006.        Dr Ananda Amarasinghe WHO/STC
                                                                                                   37
recommended during the pregnancy. However, this reported vaccination
of pregnant women may have happened due to the following reasons:
      (1) Lack of screening by the staff
      (2) Those women may have given incorrect information, probably
          intentionally
      (3) Despite good screening and correct information by the women,
          still it is possible if the vaccine is given during the first 4 weeks
          of pregnancy, the women may not have been aware of the
          pregnancy at the time of vaccination

WHO/PAHO has recommended continuing the pregnancy, even in case of
such accidental administration of the MR vaccine. (www. paho.org )
Therefore, it is recommended to continue the pregnancy of all these
reported cases, but vigilant follow up is essential. Outcomes of all these
pregnancies have to be investigated. These information should be
disseminated with the WHO and UNICEF for future reference.


Wastage
Wastage is an indicator to assess the programme process and reflects
good planning and rational vaccine management. This is much
challengeable during a mass campaign and in island settings. The
reported wastage was around 5%, which is impressive. The highest
wastage of 19.2%% is reported from Alif Dhal atoll and the lowest of zero
wastage has been reported by Raa and Seenu Atolls. Male reported 2.6%
wastage. (Table 10) The data presented in this table may not reflect the
total programme wastage, as this table data based on the limited weekly
returns received by the DPH (except for Male).

Table 10: MR Vaccine Wastage by Atolls


 Atoll                           Wastage (%)                     Atoll              Wastage %

 Male                                  2.6           Vaav                                12.4
                                       1.0                                               7.2
 Haa Alif                                            Meem
                                       NA                                                5.8
 Haa Dhaal                                           Faaf
                                       NA                                                NA
 Shaviyani                                           Dhaal
                                       1.4                                               NA
 Noon                                                Thaa
                                        0                                                4.9
 Raa                                                 Laam
                                       2.4                                               4.3
 Baa                                                 Gaaf Alif
                                       0.5                                               13.1
 Lhaviyani                                           Gaaf Dhaal
                                       3.4                                               12.4
 Kaaf                                                Gnaviyani
                                       3.5                                                0
 Alif Alif                                           Seen
                                       19.2                                              5.4
 Alif Dhaal                                          MALDIVES


Measles Rubella Immunization Campaign, Maldives, 2005-2006.        Dr Ananda Amarasinghe WHO/STC
                                                                                                   38
Note: NA – Not available

Reporting
During the training and in guidelines, the importance of maintaining a
good reporting practice during the MR campaign is highlighted. All
necessary forms and registers are supplied to all Atolls adequately. (Table
5)

However, the timeliness and completeness of the weekly reports received
from the Atoll is unsatisfactory. Some Atolls had never sent the weekly
report to the DPH. The DPH identified this issue and alternate data was
obtained on a daily basis by telephone. Though not a very cost effective
method, it was continued thoughout the programme. Part B of the
weekly return sent by Atoll is either missing or incomplete. Part B gives
the AEFI information and this may be one of the possible reasons for
under reporting of AEFI.


Field Visits

The field visits by the national team including WHO/STC per se is a
useful monitoring and evaluation tool. A member from UNICEF and the
senior paediatrician at the IGMH also joined to the team for few visits.
The team visited the following Atolls during the MR campaign and carried
out the RCA too: Haa Dhal (Kulhudhuffushi , Hanimadhoo), Haa Alif
(Dhidhdhoo, Filladhoo), Baa (Eydhafushi), Laviyani (Naifaru), Alif Dhal
(Dhigurah), Kaafu (Dhiffushi) and, Gaaf Dhal ( Thinadhoo, Madaveli)

During the field visits, the team made the following observations:
¬ The devoted Atoll and Island public health staff is the main
  contributory factor of the success of the programme. Team spirit is
  well demonstrated. Except in a very few institutions, the good and
  friendly collaboration between vaccination team / public health staff
  and the hospital staff was noticed.

¬ Vaccination sites and time are much convenient to the public and
  accessibility wa s ensured. Some atolls (e.g.: Haa Dhal) have
  conducted the clinics from morning till late evening, enabling all
  people to get the vaccination.

¬ A good awareness among the public was noticed. Some atolls (e.g.;
  Laviyani Atoll) have developed local IEC materials and many other
  activities for public awareness, particularly with local donor support.
  One of the leading sources of information is the health staff.




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              39
¬ Not a single complain from the public was received. However, the
  elements of public discouragement by the clinicians were well noticed
  for unknown reasons. Particularly the advocacy towards MMR was
  noted. This may have had some effect on the campaign, particularly
  for non compliance.

¬ There was no shortage of vaccine or any other supply at any level
  reported

¬ Maintenance of the cold chain was good.

¬ Injection safety and safe waste disposal we re assured at all places.

¬ A very few AEFI wa s observed. But no major events of AEFI were
  noticed.

¬ The quality of the programme would have been improved much, if
  proper training has been c onducted.




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              40
                       5.0 POST CAMPAIGN ACTIVITIES

5.1 M OP-UP CAMPAIGN

If the set target coverage is not obtained, WHO recommends conducting a
mop up campaign following the nation wide mass immunization
programme in order to get the highest immunization coverage.
Conducting a mop up immunization programme is not a result of the
failure of the MR campaign, but is only a continuation of the MR
campaign as phase II. Planning is an essential component in a mop-up
campaign, as it is done during the MR campaign.

Islands and Atolls, where coverage of MR campaign is over 95%, do NOT
need to conduct a mop-up campaign, as they have already achieved
expected set targets of the MR campaign. Areas, where coverage is
between 90% - 95% may or may not conduct Mop – up campaigns. The
decision to conduct Mop-up in those areas depend on the burden of the
disease in the area and the cost effectives to reach the target. All areas,
where coverage is below 90%, it is necessary to conduct mop-up
campaign.

During the Mop-up campaign all target population who have missed or
not received the MR vaccine during the MR campaign will be immunized.
The priority target group will be: school children, teachers, resort
workers, fi shermen, and workers at construction sites, National Security
Service and foreign workers who are in Maldives for a long period. All
these groups are potential source s of the outbreaks and therefore
immunization of those who are in the eligible age and sex groups is
important.

According to the available statistics, there are around 10,000 fishermen,
10,000 in resorts/ hotels/ restaurants and, around 1,500 in the armed
and security forces in the country. Majority of them are males and may
be over 25 years. It is not necessary to immunize all of them, but the
working males aged less than 25 years and females below 35 years need
to be vaccinated. Identifying of these population and their locations is the
challenging task in mop-up micro planning. It will be much useful in
developing strategies for the mop-up campaign.

The MR campaign did not much focus on the resorts for two reasons: the
available human resource and transport facilities are limited and that
may inadequate to cover the resorts, while conducting the MR campaign
in islands. Secondly, there may be a possible low cooperation from the


Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              41
resort management during the high tourist season in the country. The
RCA revealed that around 23% (Figure 2) are out of the islands and have
not received the MR vaccine. A significant proportion of them
undoubtedly are in the resorts. It is clear that the majority of MR
campaign target groups in the resorts is not vaccinated and need to be
covered during the mop-up campaign

There are around 40,000 foreign employees in the Maldives. Of them
20% is at construction sites, 30% in the tourist industry, 7% in hotels
and restaurants, 8% in educational institutions and 8% in
manufacturing industries. This large fleet of foreign employees is a
                                   ell
potential source of infection as w as a susceptible group to measles
and rubella. Most of them are working on long term contracts and
therefore vaccination of foreign employees who are in the country target
age groups is important. Majority of them are male s and over 25 years of
age, but details by age and sex are not available. According to estimates,
this is 8,000 to 10,000. This group will be immunized during the mop-up
and statistics will be maintained separately. However, this number is not
included into the MR campaign national target estimates, due to
possible erroneous statistical conclusions in the national statistics in
future.

Planning : The p  lanning of the Mop up programme will begin in mid
January 2006. The Mop-up campaign may take one month to complete
and the institution based approach is more appropriate due to limited
resources (particularly man power).

A post MR campaign National review meeting has to be conducted to
identify the strengths and weaknesses of the program. Along with
detailed quantitative information, this review should analyse experiences
from the field. The lessons learnt should be used to improve mop – up
campaign. All Atoll public health managers/ CHS will participate in this
review. The outcomes should be used to evaluate the effectiveness of
mop-up campaign preparations and implementation. During this review
programme, it is of utmost importance to identify the strategies to be
implemented during the mop-up campaign by each atoll.

Identifying and listing of the remaining target groups by name and places
are the first steps at the planning stage of the mop-up campaign. Except
in Male, this is feasible; for this purpose MR Vaccination registry and the
lists of the target population prepared in MR Campaign micro planning
could be used as guidance. Once the number not vaccinated is identified,
estimates of vaccines and other supplies have to be prepared by Islands
/ Atolls. DPH has to order and keep ready the supplies by end of
February 2006. (Annex IX: MR/MP E1) However, it is unlikely that
vaccine and injection safety items have to be ordered, as during the MR


Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              42
campaign orders had been placed to cover the total target population in
the country. After receiving the Atoll estimates for mop-up, the DPH will
finalize the distribution plan and quantities of supplies required by each
Atoll. (Annex X: MR/MP D1)

While setting the time period for mop-up campaign, it should avoid major
national events (e.g.; election, census, and religious festivals), school
holidays, bad weather seasons etc., However, mop-up campaign has to
be completed as early as possible, preferably by mid 2006.

Inter sectoral collaboration is an essential component in the mop up
campaign. The support from the Ministry of Education, Ministry of
Tourism and Atoll Ministry is crucial particularly as it is planned to carry
out the institution based mop-up in the country.

Training: The above mentioned review meeting is the expected training
opportunity and there is no necessity to conduct a special training
programme, as training has already been done during the MR campaign.
Atoll based CHS may need a special awareness programme /training to
conduct Mop-up campaign, as it is the ir responsibility to carry out the
mop-up campaign. This is the reason for all Atoll public health managers
/ CHS have to be invited for the national review. The objective of this
awareness is to explain the necessity and how to carry out the Mop-up
campaign in local settings.

Advocacy: Unlike in the MR campaign, mass media may not be utilized,
as it can create a public confusion. Target group focused advocacy is the
most appropriate strategy. Therefore, individual and small group based
advocacy approaches will be effective. A small scale poster campaign may
be used, to create some awareness among the community. Therefore ,
advocacy in mop-up campaign may not require a large amount of fund
allocation. Community based social mobilization will be much useful in
the mop-up campaign. However for Male, a special advocacy / awareness
programme has to be considered.

Conducting the Mop-up campaign: It is recommended to have one or
two teams for each Atoll to carry out the Mop-up campaign. Special
mobile team will visit the schools, resorts and other work places if the
reported MR coverage among those groups is low and institution based
special clinics will be conducted. In addition to these mobile teams, MR
vaccine should be made available at the all health posts / health centres
/hospitals (eg: at the IGMH and Male Health Centre, in Male). These
institutions may have a special cli nic for MR vaccination once a week.
This will minimize the vaccine wastage. A proper preparedness for the
AEFI management has to be ensured during the Mop-up campaign as
done during the MR campaign.


Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              43
Monitoring and Evaluation
It will be similar to the MR campaign. It is the responsibility of the Atoll
managers to monitor the Mop -up campaign through field visits and daily
returns. (Annex XI: MR/MP R1) All supervision check lists, return forms
used in the MR campaign should be used in the Mop-up campaign too. It
is important to highlight, that the AEFI surveillance has to be continued,
as in the MR campaign. After completion of the Mop-up campaign Atoll
will send the final summary report to the DPH. (Annex XII: MR MP/R2).
The DPH has to prepare a final evaluation report for the country with the
necessary recommendations to ensure the prevention and control of
measles and rubella in the country.

Table: Outline of the Mop up Campaign Activity Plan
              Activity              Time Schedule                                 Responsibility
 Preparedness for post M R Campaign                      Before    end       of   DPH
 National Review                                         January 2006             Atolls
    • Compiled MR Information
    • Identify Successes & problems
    • Identify      the    number       NOT
        immunized during campaign*
           - By Geography
           - By risk category
 Post MR Campaign National Review :                      1 -2 week of February    MoH
    • Identify and finalize strategies to be             2006                     DPH
        used in the Mop -up campaign
    • Setting Targets
    • Programme scheduling
    • Training/awareness for Atoll staff

 Aw areness programme / Training for                     3 -4 Week s   of   Feb   DPH
 Atoll based CHS                                         2006
    • Decisions      of  National  Review
        meeting
    • Programme implementation strategy
 Planning & Preparation                                  March 2006               DPH
    • Provision of supplies                                                       Central   Supply
            - Vaccines                                                            Unit
            - Injection safety                                                    Atolls
            - Forms/ Returns
            - Stationary
    • Advocacy
    • Team training (if necessary)
 Programme Implementat i o n                             April or May 2006        MoH
    • Medical Institution       and other                                         DPH
        institution ( School / work place)                                        Atolls
        based
    • Supervision and Monitoring
 Programme Evaluation                                    May or June 2006         DPH




Measles Rubella Immunization Campaign, Maldives, 2005-2006.      Dr Ananda Amarasinghe WHO/STC
                                                                                                 44
5.2 DISEASE SURVEILLANCE AND GUIDELINES

A sensitive measles, rubella and CRS surveillance system must be firmly
established, most importantly to measure the impact of the campaign on
the disease burden in the community. The MR campaign is one time
intervention to reduce the virus transmission, disease morbidity /
mortality and to boost the immunity among the community. However the
impact of the MR campaign will assess on the future morbidity and
mortality pattern of the measles and rubella /CRS in the country.
Therefore it is strongly recommended to continue the disease surveillance
for measles and rubella /CRS. At present CRS is not a notifiable disease
in Maldives. The Ministry of Health shall make the CRS as a notifiable
disease in 2006.


5.2.1 M EASLES SURVEILLANCE
Measles surveillance is critical for measuring the progress towards the
goal of measles elimination in the country. Therefore efforts are needed to
improve the quality of measles surveillance throughout the country,
particularly in post MR campaign period.

When measles elimination is the goal, surveillance must be case based
with the principal objectives of:
• Immediately detecting any suspected cases
• Confirming cases by laboratory diagnosis
• Identifying importations and possible sources of infection.

Measles surveillance should include surveillance for measles disease and
surveillance for persons susceptible to measles. Surveillance data should
guide health personnel in the decision making needed to implement the
proper strategies to consolidate measles control and guide the way for
the elimination of the disease.

Case-based surveillance
Case-based means that the surveillance system collects minimum data
set at national level on each case, including, but not limited to
information on age, gender, vaccination status, place of residence, travel
history, da te of rash onset, disease outcome, etc. The data on each case
are usually defined as the minimum data set.

Case-based measles surveillance in elimination settings usually implies
laboratory support for confirmation of the clinical diagnosis via
identification of measles-specific IgM-antibodies and/or identification of
measles virus in appropriate clinical specimens. Case -based surveillance


Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              45
allows for analysis of measles epidemiology to guide control efforts. As
countries approach elimination status it becomes important for every
suspect case of measles to be reported and included in the national
database.

When measles is still relatively common (eg: during an outbreak), case-
based surveillance may need to be selective - only collecting the data on
a sample of cases or a minimal data set.

Case Reporting
At present measles is notifiable in the Maldives and the reporting
practice is impressive. Its includes both indoor and out door reporting.
                                                       s
Case based surveillance is in place, but certainly need improvement.

Case Definition
A standard clinical case definition for measles such as the one
recommended by WHO should be introduced: “Any person with:
generalized maculopapular rash (i.e. non-vesicular), and history of fever
of 38°C (101°F) or more, (if not measured, “hot” to touch) and at least one
of the following: cough, coryza (i.e. runny nose) or conjunctivitis (i.e. red
eyes); or any person in whom a health professional suspects measles.”

Embarking on measles elimination requires new surveillance elements
including:
• Informing the public of the need to bring all suspected measles cases
   to health providers,
• Reporting all suspected measles cases rather than only confirmed
   measles cases: its need to highlight, that any person in whom a
   health professional suspects measles should be reported, even though
   clinical presentation is not favourable to measles.
• Introduction of zero case reporting, meaning that even in the absence
   of cases health units should submit a report to ensure that zero cases
   actually reflect the absence of the disease.
• Inclusion of private practitioners, other reliable community sources of
   information, and laboratories in the notification network.

Case Investigation
Investigate every report of a suspected case within 48 hours.
Investigation of any suspected case with collection of the following data
on a standard case investigation form is important.
• Basic clinical data to ensure that reported cases fit the standard
   measles case definition;
• Source of infection data to identify areas where circulation of the
   measles virus is still active and to detect importations; In Maldives,




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              46
    there are around 40,000 foreign employees and they may be a
    potential source of infection in the country.

Present data collection format needs modification to cater to present
surveillance objectives, particularly with the objective of the disease
elimination. Therefore it is recommended to use WHO field tested case
investigation format with the necessary modification to meet the
surveillance requirement in Maldives. (Annex XIII)

It is recommended to use a line -listing form with a single case
identification number for each case to standardize the data collection,
facilitate follow-up of each case and permit monitoring of surveillance
indicators. Data on age group (i.e. <1year, 1-4 years, 5-14 years and >15
years) and sex should be reported for all cases. Making spot maps by
plotting cases according to their place of residence is useful and in future
this may be expanded with the GIS software system. These will be helpful
in planning immunization supplementary activities in future.

Laboratory Surveillance
Maldives is in the mid-phase of measles elimination, and that has
introduced case-based surveillance, and therefore all suspected cases
should be confirmed by measles IgM testing. However, once the Maldives
is in the final stages of measles elimination, in addition to ensuring
measles IgM testing for all cases, isolation of measles virus for its further
characterization (for genomic sequencing and mapping purposes)
becomes critical. Therefore it is recommended to introduce laboratory
investigation of all suspected cases to confirm or discard a measles case.
Laboratory investigations are not undertaken currently in all suspected
cases, because in Maldives part of the cost of laboratory test is borne by
the patient and when clinician is confident of the clinical diagnosis
he/she reluctant to put the patient through unnecessary expense. It is
therefore recommended to carry out laboratory investigations in all
suspecte d cases and a way has to be found to achieve this without
additional cost to the patient as this is being carried out for public health
purposes. It is equally important to ensure the timely collection and
testing of laboratory specimens, the interpretation of laboratory results
and regular feed back to the health facilities and patients.

Case definition in Lab Surveillance
A laboratory confirmed case is any suspected case that is laboratory
confirmed or epidemiologically linked to a laboratory -confirmed case.

The recommended procedure for laboratory confirmation of acute
measles cases is detection of measles specific IgM antibody in a serum
sample obtained at first contact with the suspected case; preferably
within an optimal timing of four to 28 days


Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              47
For measles virological surveillance, the preferred specimens are either a
urine sample or a throat/nasal swab (or both) taken at first contact with
the suspected case. It is very important to take the specimen for virus
isolation at first contact with the suspected case. Urine, the most
practical specimen to collect for measles virus isolation, should be
obtained within 7 days of rash onset and forwarded to a reference
laboratory capable of performing measles virus isolation. Greatest
success for virus isolation or RT-PCR can be expected if the specimen is
taken within 0 to 5 days of rash onset. Virus isolation rates are 40% of
IgM positive cases if specimens are taken 0 to 5 days after rash onset,
whereas no viruses can be isolated after six days.

However, IgM should be the priority for laboratory confirmation of
reported cases and, not viral isolation. A concern was raised about the
differentiation of IgM as to whether this is induced by wild virus or
vaccine, especially when doing mass campaigns. IgM usually lasts for
about 28 days after vaccination and it should disappear after 2 months.

Data management is critical to the success of any system and it is
important to give it sufficient attention from the onset of the measles
laboratory network. A system to efficiently collect, validate, analyse and
transfer data needs to be developed, which is driven by the three
principles of good data management which are completeness, accuracy
and timeliness.

Serological Studies
The most direct way to estimate the susceptibility profile in the country
is through an age stratified sero-survey, interpreting samples negative for
IgG antibody as susceptible to measles.

Post-campaign serological evaluation is optional. Maldives has not
carried out the pre -campaign sero-assessment, and therefore usefulness
of post campaign sero-survey is limited. However, if MoH wishes to
conduct a post-campaign survey, it will be done through a post-
campaign School Survey and Community Survey. The                EPI/WHO
adopted cluster sampling method will be used in these surveys to
represent all Regions /Atolls and analysis will be performed to determine
factors associated with coverage and quality of the services.



5.2.2 RUBELLA AND CRS SURVEILLANCE

WHO has recommended that all countries that include rubella vaccine in
their immunization services should conduct surveillance for CRS and


Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              48
rubella. In the CRS prevention stage, disease surveillance should focus
on detecting cases of CRS. In the CRS/rubella elimination phase (usually
conducted in conjunction with measles elimination), case -based
surveillance of febrile rash illness is necessary.

As measles control improves, increasing rubella is seen because of
increased laboratory testing of acute fever and rash cases. It is clear
rubella control also needs to be considered as part of measles control.
Good surveillance is the key to establishing rubella epidemiology and the
potential use of measles-rubella (MR) vaccine.

The measles case definition often catches rubella cases and measles is
often the first differential diagnosis; thus the programmes often are
linked and the IgM assay is very similar. Therefore, reasonable rubella
surveillance can be achieved with minimal additional cost.

Surveillance of rubella becomes a priority when the country has set a
rubella elimination target. Usually, this occurs at the time that the
country establishes a measles elimination target. In this situation,
combined measles/rubella rash illness surveillance is a key component
of measles/rubella elimination.

After a complete investigation, many suspected measles cases are
ultimately found to be rubella. Moreover, cases of the CRS have been
found in all countries of the Region that have established CRS
surveillance systems. Surveillance is carried out for CRS, which is the
main burden from rubella. Most of the time, rubella vaccine is given as
measles rubella (MR) or mumps measles rubella (MMR); therefore, there
is a link with the measles control programme.

Rubella is a notifiable disease in Maldives, but not the CRS. It is
recommended that CRS to be made notifiable and both rubella and CRS
need to have a case based surveillance practice, as is for measles in the
country. (Annex XIII & XIV)

As in measles, case based Rubella /CRS surveillance should be initiated
throughout Maldives. The purpose of CRS surveillance is to detect new or
incident CRS cases in infants; efforts should not be routinely made to
confirm CRS in older children.

Rubella Case Definitions
• A suspected rubella case
A suspected rubella case is any p atient of any age in whom a health
worker suspects rubella. A health worker should suspect rubella when
the patient presents with fever, maculopapular rash, and one of the



Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              49
following: cervical, sub-occipital, or post-auricular adenopathy; or
arthralgia/arthritis.

It will usually be impossible to distinguish rubella from measles, dengue,
or a number of other febrile rash illnesses. At the rubella/measles
elimination phase, suspected measles and suspected rubella are
combined in a single febrile rash illness surveillance category for
suspected cases.

• Laboratory-confirmed rubella case
Because of the difficulty in clinical diagnosis of rubella, laboratory
confirmation is required. A laboratory -confirmed rubella case is a
suspected case with a positive blood test for rubella-specific IgM.

• Epidemiologically-confirmed rubella case
An epidemiologically-confirmed rubella case is a patient with febrile rash
illness who has not had a blood test but has an epidemiological linkage
to laboratory confirmed case of rubella.

Case definition of CRS
• Suspected CRS case
A suspected CRS case is considered as any infant less than one year of
age in whom a healthcare worker suspects CRS. A health care worker at
any level of the health care system should suspect CRS in an infant
when:
1. One or more of the following birth outcomes are detected: congenital
cataracts, hepatosplenomegaly, patent ductus arteriosus, purpura or
hearing impairment
2. An infant’s mother was known to have had laboratory confirmed
rubella infection during pregnancy AND after a thorough physical
examination, for any reason, there is clinical suspicion of CRS in the
infant.
3. Infants with low birth weight should be specifically targeted for a
careful clinical examination for CRS specific birth defects.

• Laboratory-confirmed CRS case: A laboratory confirmed CRS case is a
patient in whom a healthcare worker initially suspected CRS that is
found to have laboratory evidence of rubella virus infection (i.e., rubella
IgM positive).

• Clinically-confi rmed CRS case: A clinically confirmed CRS case is an
infant in whom a healthcare worker initially suspected CRS, but
laboratory confirmation of rubella infection is not available. This is
generally due to the absence of an appropriate clinical specimen. Si nce




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              50
presence or absence of rubella infection could not be determined, these
cases are considered as failures of the CRS surveillance system.

• Congenital rubella infection only, without CRS: This designation is
used for an infant born to a woman infected during pregnancy. These
infants are IgM positive for rubella, however, there are no clinical
findings which are compatible with CRS. These cases should be
discarded as not being CRS, and classified as congenital rubella infection
(CRI).

• Discarded CRS case: A suspected CRS case may be discarded if an
adequate serum sample from the infant tests negative for rubella IgM
antibodies.


During the CRS prevention stage, WHO has recommended minimum
requirements of rubella and CRS surveillance are:

    •    Routine monthly reporting of the number of suspected CRS cases;
         zero reporting should be required. All suspected CRS cases in
         infants aged under 1 year should be investigated. The investigation
         should include clinical and laboratory analysis
    •    All febrile rash illnesse s in pregnant women should be investigated
    •    If a rubella outbreak is detected a limited number of suspected
         rubella cases should be investigated with rubella-specific IgM tests
         periodically during the outbreak (5 to 10 cases investigated per
         outbreak). Active surveillance (defined as regular visits to selected
         reporting sites to look for unreported cases) should be initiated to
         improve detection of suspected CRS in infants aged under 1 year
         and continued for nine months after the last reported case of
         rubella

During the CRS/rubella elimination stage, WHO recommended the
following minimum requirements:

    •    Same as CRS prevention stage, plus
    •    Routine monthly reporting of the number of confirmed rubella
         cases; zero reporting should be required
    •    All febrile rash cases, regardless of age, should be investigated. The
         investigation should include laboratory analysis of each case for
         measles and, if the result is negative, for rubella. Priority should be
         given to the investigation of febrile rash illnesses in pregnant
         women
    •    Regardless of the type of surveillance, designated reporting sites at
         all levels should report at a specified frequency (e.g. weekly or



Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              51
         monthly) even if there are zero cases (often referred to as "zero
         reporting")


Laboratory Surveillance

Rubella la boratory surveillance should be integrated with measles
laboratory surveillance. The purpose of rubella laboratory surveillance is
to detect circulation of rubella virus, not to detect every case of rubella.
Therefore, a separate rubella laboratory surveillance system is not
needed. All sera from suspected measles cases which test negative for
measles IgM antibodies should be tested for rubella IgM antibodies and
vice versa.

Rubella specific IgM is diagnostic of acute infection; IgM usually appears
within 4 days after onset of the rash and can persist up to 4-12 weeks.
Rubella specific IgG is a long-term marker of previous rubella infection;
IgG begins to rise after the onset of the rash, peaks about four weeks
later, and generally lasts for life.

Rubella virus surveillance may provide important information concerning
the viral sub-types that are currently circulating in the country. Efforts
should be made to collect several appropriate clinical specimens for viral
isolation from every documented rubella outbreak. Nasopharyngeal
aspirates are the preferred specimens for rubella virus isolation.
Specimens should be collected within 4 days of rash onset and forwarded
to an appropriate reference laboratory.

Similar to measles/rubella laboratory surveillance,              laboratory
confirmation is crucial for the diagnosis of CRS. A blood sample should
be collected from every infant with suspected CRS. For surveillance
purposes, a single serum specimen is generally considered adequate to
either confirm or discard CRS. If, however, the first sample tests negative
for rubella IgM and there exists compelling clinical and/or epidemiologic
suspicion of CRS, then a second serum specimen may be requested to
confirm CRS.

The serum immune response in CRS differs from that seen in rubella
(and from many other viral diseases). At birth, the serum of an infant
with CRS contains maternally derived rubella-specific IgG antibodies as
well as IgG and IgM antibodies synthesized by the fetus. Maternal
rubella -specific IgG is also found in normal infants born to women who
are immune to rubella. Therefore, rubella-specific IgM is used to
diagnose congenital rubella infection in infants. In infants with CRS,
rubella -specific IgM can be detected in nearly 100% at age 0-5 months;
about 60% at age 6-12 months; and 40% at age 12-18 months; IgM is


Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              52
rarely detected after age18 months. Infants with CRS shed rubella virus
for long periods. Rubella virus can be found in the nasopharyngeal
secretions of more than 80% of infants with CRS during the first month
of life, 62% at age 1-4 months, 33% at age 5-8 months, 11% at age 9-12
months, and only 3% during the second year of life. Infants with CRS
who are shedding rubella virus are infectious and appropriate infection
control measures should be instituted. It is particularly important to
prevent exposure of nonimmune pregnant women to these infants.

Serological studies
Serological studies may be a useful adjunct to clinical surveillance at any
stage of rubella control. Relatively simple serological studies may be
based on samples obtained from women of childbearing age at antenatal
clinics. Large age-stratified community -based sero-surveys can evaluate
age-specific acquisition of rubella antibodies. This information can be
used to develop models that estimate the effects of different CRS
prevention and rubella control strategies. However, conducting such
serological studies is optional to the Maldives and no need to carry out as
a routine activity.

Sero-surveillance among women of childbearing age
As the public health burden of rubella relates to the risk of infection of
pregnant women, which in turn may cause CRS in their offspring, many
countries have conducted sero-surveys to determine the proportion of
women of childbearing age who are susceptible to rubella. An individual
who is susceptible to rubella infection will have a negative blood test for
rubella -specific IgG. A single cross-sectional survey of IgG sero-
prevalence in women of childbearing age is of limited usefulness in
demonstrating disease burden. Although a high level (e.g. >20%) of
susceptibility is likely to indicate a high risk of CRS in that population, a
low level of susceptibility cannot be taken to mean no risk of CRS. Even
when susceptibility levels in women are below 10%, CRS can occur.
Therefore serological surveys are of most use to monitor trends in the
proportion of adult women who are susceptible, in particular in countries
(eg. Maldives) which have introduced rubella vaccination for women of
childbearing age. Such data will be co      mplementary to rubella vaccine
coverage data in the same target group.

Antenatal clinics and similar facilities are appropriate as locations for
these kinds of studies when:
• The proportion of pregnant women who attend at least once is high
(>90%);
and
• The pregnant women who attend already have blood specimens drawn
for other purposes (e.g., haemoglobin or blood sugar tests) and portions
of these specimens are leftover. Epidemiological studies that require the


Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              53
examination of anonymous “leftover “ samples of blood may be conducted
without the consent of the individuals concerned, as long as their right to
confidentiality is ensured by the study methods. Anonymity can be
achieved by removing personal identifiers from information collected
about persons from whom the specimens were collected;
or
• Serological specimens are being collected from the same population for
other purposes and permission can be obtained to use the samples for
rubella tests.

Cross-sectional community-based survey
A cross-sectional community-based survey will be expensive if it is
conducted solely for rubella. Much of the cost is related to field work.
Therefore combining rubella sero-surveys with serological studies of
other infections such as measles, Dengue, HIV or hepatitis B should be
considered to reduce the cost. However these sero-surveys are optional,
and should not be a part of routine disease surveillance in Maldives.


Fever Rash Surveillance
As mentioned early, introduction of fever rash surveillance is
recommende d. All fever cases (>380 C ) with maculopapular, non
vesicular rashes should be reported. Maldives has a good reporting
system including the out patients, which covers the country prevailing
diseases such as measles, rubella, and dengue . Therefore it is no
necessity to introduce an additional separate reporting system for fever
                                     ed
rash group of diseases. What is need is the DPH to alert for clustering
of fever-rash cases (More than 5 cases per week or 10 cases per month
from a single island OR more than 10 cases per week for the country)
reported by daily returns and thereby continue fever rash surveillance
irrespective of reported clinical diagnosis. This includes an early
laboratory support, regular data analysis and dissemination of the
information.



5.2.3 OUTBREAK RESPONSE

Outbreak investigation and management should also be a component of
every measles/rubella control programme. An outbreak consists of an
increase in the number of cases reported compared with cases reported
previously in the same areas during similar time intervals in non
outbreak years. The occurrence of any outbreak is an opportunity to
intensify surveillance, to understand why cases are occurring and to
adjust immunization strategies accordingly. Depending on the level of



Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              54
measles and rubella control and coverage in a country, responses to an
outbreak will differ.

With measles and rubella virus circulation interrupted in most parts of
the country, outbreaks provide a special opportunity for the entire
country to obtain information that can be used to prevent future
outbreaks. Therefore, investigation reports from all outbreaks should be
made available. DPH should assist in the collection and dissemination of
this information throughout the country.

Once measles incidence has been drastically and persistently reduced
due to increased immunization coverage, it is appropriate to implement
strategies aiming at the prevention of periodic measles outbreaks. The
three main objectives of surveillance in order to prevent outbreaks are to:
• Identify the populations at highest risk of measles.
• Understand the changing epidemiology of the disease (so as to modify
   immunization strategies accordingly).
• Predict the occurrence of outbreaks.

In the mid and elimination phases, every case of measles needs to be
laboratory tested. However, in an outbreak, there is no need to test every
case and will need to rely on the epidemiological link to laboratory-
confirmed cases.

Once rubella has been identified as the cause of an outbreak of febrile
rash illness, particular attention should be paid to the detection of
rubella in women of childbearing age.

Present MR campaign has covered males below 25 years and females
below 35 years. Measles immunization was introduced in 1985 and
therefore all those born before 1985 and not received the MR vaccine
during the MR campaign are at increased risk for measles during an
outbreak. These groups have also been responsible for sustaining
measles outbreaks and for transmitting measles to susceptible persons
of other age groups. Since the epidemiologic situation may differ between
Atolls, it is not possible to give blanket recommendations about which
groups of adults to be vaccinate d in all Atolls. When measles virus
circulation is suspected, consideration should be given to quickly
vaccinate persons within the following groups: teachers, military
personnel and persons living/working within institutions such as prisons
and, large factories.

To obtain information that can be used to prevent and control future
outbreaks, a ppropriate investigations and analysis must be conducted
for all measles / rubella outbreaks. Efforts are needed to determine



Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              55
sources of measles / rubella virus introduction, transmission patterns
and specific risk factors for acquiring measles / rubella.

Table :Measles and Rubella/CRS Surveillance Indicators                                               Deleted: ¶
                                                                                                     ¶

      Activity                                      Indicator                          Target
Daily / Monthly                                                                       100%
/Quarterly         Number Reported (number of facilities reporting
Reporting          measles/rubella/CRS         cases      during     a
                   day/month/quarter should be compared with
                   the total number of facilities that should
                   report): Zero case reporting is essential,
                   therefore reports of all facilities should be sent
                   Timeliness [number of measles/rubella/CRS                          100%
                   cases reported on time (within 24-48 hours)
                                                          e
                   during a month/quarter should b compared
                   with the total number of cases reported during
                   the given time period]
Case Investigation Number Investigated (The percentage of                             100%
                   suspected cases that have been investigated)

                           Timeliness (The percentage of suspected cases              100%
                           that have been investigated within 48 hours)

                    Completeness (Number of completed case base                       100%
                    reports should be compared to the number of
                    total case base reports received during the
                    given time period)
The number of Atolls should be categorized as follows:
notified            No cases
measles/rubella     1-10 cases
cases in each Atoll 11-100 cases
should          be over 100 cases
monitored           No information
annually
Outbreak            Geography :number of Atolls with fever rash
                    outbreak
                    Investigation: Number of fever rash outbreaks                     100%
                    investigated, out of total fever rash outbreaks
                    reported
                    Laboratory: Number of laboratory confirmed                        100%
                    outbreaks, out of all reported fever rash
                    outbreaks

Laboratory                 The percentage of cases with laboratory                    100%
Surveillance               samples taken (during an outbreak, it is not
                           necessary to take laboratory specimens for all
                           cases)
                           The percentage of cases with laboratory results            >80%


Measles Rubella Immunization Campaign, Maldives, 2005-2006.     Dr Ananda Amarasinghe WHO/STC
                                                                                                56
                           (IgM)available within 10 days of collection
Immunization               The percentage of measles / rubella cases that
status                     have been immunized previously

5.3 STRENGTHENING EPI ACTIVITIES                                                                   Deleted: ¶


Strengthening of routine EPI programme in post MR campaign period is
of utmost importance. This is vital for impeding the accumulation of
susceptible individuals in the population.

The present EPI sche dule does not include the rubella. The burden study
done in 2003 has recommended that rubella be included in the routine
EPI. This has been much empahasized following MR campaign, because
the long term benefit of the MR campaign will depend on the
sustainability of high immunity against the rubella infection in the
community. The MoH has focuse d the mumps epidemiology in the
country too. Therefore, the MoH is planning to introduce MMR vaccine
into the routine immunization from 2006.

It is recommended to ensure the implementation of following activities
and follow up them, in order to achieve the goals and objectives of the
EPI programme of the country ;

•   Routine vaccination of infants (keep-up vaccination) is a critical
    component of the country measles eradication strategy. Efforts are
    needed to vaccinate 100% in every Island / Atoll.

•   Age appropriate immunization is important. During the field visits, it
    has been revealed, that in some islands, immunization sessions are
    being conducted once in 3 months only. This may be due to the
    limited human resources and difficulties in transport. However, efforts
    should be made to conduct the immunization clinics at more regular
    basis, at least once in 2 months to ensure the age appropriate
    immunization.

•   Vaccine coverage must be monitored at the Atoll level using
    appropriate denominators for the target population. Ranking of Atolls
    / Islands by routine immunization coverage as: <80%, 80-94%, >95%

•   Maldives should incorporate rubella-containing vaccine (MR or MMR)
    into childhood vaccination programs, both as part of routine
    childhood immunization at 18 months or at 3 years, and as part of
    the follow-up campaigns.




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              57
•   MR campaign did not cover children below 6 years of age and these
    children therefore need to be covered wi th MR or MMR. This should
    be done without any delay, as otherwise they are at increased risk of
    the rubella in future. This could be done at the school entry or pre
    school settings.

•   Healthcare workers are at increased risk for being exposed to measles
    virus and for being a potential source of virus transmission in health
    facilities. Persons working in healthcare settings who have contact
    with children and persons with infectious diseases (measles / rubella)
    should be vaccinated against measles, regardless of disease history or
    vaccination status. The use of Rubella containing vaccine (MR) is
    strongly recommended.

•   Moreover, targeted efforts are needed to reduce the number of rubella
    susceptible women of childbearing age (who has missed the MR
    vaccine during the MR campaign). Strategies, such as post-partum
    immunization, immunization in family planning clinics, immunization
    in schools and workplaces can be used to protect these women.

•   A general requirement for rubella immunization of hospital personnel
    at risk of exposure (e.g., obstetrics, paediatrics, and ophthalmology
    staff) against rubella will help in preventing Hospital Associated
    Infection (nosocomial spread) of rubella.

•   There are substantial data available documenting the absence of
    significant risk of rubella vaccination during pregnancy. However,
    pregnant women are generally not vaccinated. This is to avoid the risk
    of the vaccine being implicated should there be an unrelated adverse
    outcome of the pregnancy. However, a few cases of MR immunization
    among the pregnant women have been reported. All these pregnancy
    out come need to be followed, investigated and these information has
    to be disseminated with the WHO / UNICEF

•   It is recommended to conduct National /Regional / Atoll level EPI
    review meetings regularly, preferably quarterly or at least once a year.
    This should be done jointly by public health and clinical staff to make
    it more useful and to be benefited by the country.




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                              58
                                                                                                     Deleted: ¶

                               6.0 RECCOMONDATIONS

• Mop up campaign is recommended for all Islands / Atolls, where MR
    campaign coverage is below 9   5%. House to house mop-up is                               not
    practical in Maldives, hence institution based mop-up will be                              the
    choice. All those who have missed the MR vaccination should be                            the
    target. School children, teachers, fishermen, resort workers are                          the
    leading target groups. In addition, foreign employees in eligible                         age
    groups need to be vaccinated.

•   CRS to be made a notifiable disease.

•   Case based surveillance is proposed for all measles, rubella and CRS
    cases. Pre sent case investigation form of measles need to be modifi e d
    and for rubella /CRS forms to be introduced.

•   All reported cases of measles, rubella and CRS need a laboratory
    confirmation at Government cost.

•   Incorporation of fever rash surveillance system to the present disease
    surveillance practice.

•   All reported outbreak of measles and rubella need to be investigate d.
    However during an outbreak, laboratory confirmation is not necessary
    for all cases, but a sample is adequate. This will be a part of proposed
    fever rash surveillance.

•   Serological studies are optional, and should not be a part of routine
    disease surveillance.

•   AEFI surveillance activities to be strengthened

•   Maldives should incorporate rubella-containing vaccine (MR or MMR)
    into childhood vaccination programmes, both as part of routine
    childhood immunization at 18 months or at 3 years, and as part of
    the follow-up campaigns.

•   MR campaign did not cover children below 6 years of age and these
    children therefore need to be covered with MR or MMR. This should
    be done without any delay, as otherwise they are at increased risk of



Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
                                                                                               59
    the rubella in future. This could be done at the school entry or pre
    school settings.

•   Healthcare workers are at increased risk for being exposed to measles
    virus and for being a potential source of virus transmission in health
    facilities. Persons working in healthcare settings who have contact
    with children and persons with infectious diseases (measles / rubella)
    should be vaccinated against measles, regardless of disease history or
    vaccination status. The use of Rubella containing vaccine (MR) is
    strongly recommended.

•   Moreover, targeted efforts are needed to reduce the number of rubella
    susceptible women of childbearing age (who has missed the MR
    vaccine during the MR campaign). Strategies, such as post-partum
    immunization, immunization in family planning clinics, immunization
    in schools and workplaces can be used to protect these women.

•   There are a few reported cases of MR immunization among pregnant
    women. All these pregnancy outcomes need to be followed,
    investigated and outcome information disseminated with the WHO /
    UNICEF.

•   It is recommended to conduct National /Regional / Atoll level EPI
    review meetings regularly, preferably quarterly or at least once a year.
    This should be done jointly by public health and clinical staff to make
    it more useful and for benefit of the country.




Measles Rubella Immunization Campaign, Maldives, 2005-2006.   Dr Ananda Amarasinghe WHO/STC
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