Role of Schools - in Implementation of Measles catch-up campaigns 45 minutes –Content slides 25-30 max Meeting of Principals of Pvt. Schools

Introduction Measles is a leading cause of childhood mortality Infants and young children, especially those who are malnourished, are at highest risk of dying. Measles outbreak surveillance data reveals that around 90% of the measles cases are in the age group of <10 years. Review of Indian Literature: Median case fatality ratio (CFR) of measles 1.63%* Because measles infection is so common, even with low CFR there are many deaths which are “preventable” with a vaccine. The national coverage for measles vaccine is only 69% (DLHS 3) At 85% vaccine efficacy, this means 41% (10.3 million) children are susceptible to Measles 2 2

Disproportionate burden of measles mortality in India India: 60,000-100,000 estimated Measles Deaths (2008) The burden of disease has shifted from Africa, and India now accounts for an estimated ~67% of global measles mortality. Ten states account for over 95% of the estimated measles deaths in India. To reach the 2010 goal, an estimated 204 million children between nine months and 10 years of age in these states need to receive measles immunization by 2010. Some progress has been made. The National Technical Advisory Group on Immunization met in June 2008 and recommended that a second opportunity for measles immunization be introduced either through routine services (in states with routine coverage >80%) or through SIAs. A few weeks ago, the government met with 4 high priority states (UP, Bihar, Rajasthan, and Madya Pradesh) and agreed to set up measles surveillance and begin to formulate Plans of Actions for mass campaigns. 67% = 1000 death Data source: WHO/IVB, November 2009 Dots are randomly distributed in countries

Measles disease An acute viral infection Measles case, Badaun district, Islamnagar block, Jan 2010 An acute viral infection Airborne transmission via respiratory secretions or aerosols Classic manifestations: Maculopapular rash Fever The “3Cs”: Cough, Coryza (runny nose), Conjunctivitis (red eyes) Complications and mortality highest in children < 2 yrs and in adults Can occur in vaccinated but disease is less severe and rarely fatal Viral multiplication occurs principally in the respiratory tract

Measles complications Corneal scarring causing blindness Vitamin A deficiency Older children, adults ≈ 0.1% of cases Chronic disability Corneal scarring- Associated with vitamin A defiency: Historically the most common cause of blindness in children in Africa, India Encephalitis- Older child more typically, High mortality rate, Survivors high rate of disability as here Pneumonia & diarrhea : Pneumonia usually bacterial. Most common cause of post-measles death Note also the skin peeling, a characteristic sign of a healing measles rash Pneumonia & diarrhea Encephalitis Diarrhea common in developing countries Pneumonia ~ 5-10% of cases, usually bacterial

Govt of India decision in 2010 Global Context: Worldwide measles vaccination delivery strategies, mid-2010 Govt of India decision in 2010 to introduce MCV2 Acknowledge that India WAS but no longer is the only remaining country using a single dose of MCV. MCV1 & MCV2, no SIAs (40 member states or 21%) MCV1, MCV2 & one-time catch-up (36 member states or 19%) MCV1, MCV2 & regular SIAs (57 member states or 28%) MCV1 & regular SIAs (59 member states or 31%) Single dose (1 member state or 1%)

Principles of control & rationale for second dose Live attenuated vaccine gives long term immunity Confers immunity to 85% children when given at 9-12 months of age Confers immunity to 95% persons when given at >12 months of age Persons who have failed to respond with first dose will almost always become immune with second dose As coverage is never 100%, 1 dose schedule can never achieve 95% population immunity. Key slide. #1: Although VE 85% at 9 months, in India we cannot delay first dose as there is high rate of measles transmission and mortality (CFR) from measles is higher in infants. Emphasize Point #2. Point #3: Example: 100 infants in a population: immunize all at 9 months, 85 become immune. Population immunity 85%. Immunize all 100 children again when they are >1 year. 85 were immune and will remain immune. Of the 15 who were susceptible, 95% will become immune and only 5% of 15 (=0.75) or 1 child will remain susceptible. So susceptible = 1/100 = 1% and population immunity = 99% exceeding 95% immunity needed for threshold. If coverage is <100%, population immunity achieved will be lower.

Immunological basis for MCV2 MCV2 is necessary to: Epidemiologic rationale: Immunize those vaccinated who did not sero-convert (Second opportunity) Programmatic rationale: Reach children missed by routine services – left-outs or drop outs (first opportunity) Ensure high level population immunity (herd immunity when coverage >95%)

National Technical Advisory Group on Immunization NTAGI has recommended States with MCV1 coverage <80%: Second opportunity through measles catch-up campaigns in 9 mo-10 yrs age group States with MCV1 coverage >80% second dose (MCV2) through routine immunization Applying DLHS-3 survey data 14 states which qualify for catch-up campaign 21 states which qualify for MCV2 9 9

….Benefit after measles vaccination Bullet points Bullet Points

2nd opportunity of Measles vaccine : State specific Delivery strategies MCV1 coverage national average : 69% Catch-up campaign : 14 states MCV1 <80% MCV2 through RI : 17 states with MCV1 > 80% MCV1: Coverage of Measles containing vaccine per DLHS-3; CES-06 for Nagaland 11 11

Measles SIA phasing plan, India State Total number of Districts Districts covered in Phase 1 Districts covered in Phase 2 Number of Districts for Phase 3 ARUNACHAL PR. 16 1 15 ASSAM 27 26 BIHAR 38 5 18 CHHATTISGARH 9 GUJARAT 32 22 HARYANA 21 JHARKHAND 24 19 MADHYA PRADESH 50 13 MANIPUR 8 MEGHALAYA 7 6 NAGALAND 11 10 RAJASTHAN 33 23 TRIPURA 4 3 UTTAR PRADESH 75 72 Total 365 45 153 167 Target Population ~129,597,214 13,845,686 40,167,580 ~75,583,948 Coverage (% Achieved) 12,076,836 (87.2%) 36,001,191 (89.6%) As of date 24th July, 2012

Catch-up campaign: Basic vaccination strategy … 1/2 Target age group: 9 months to <10 years (irrespective of their prior measles immunization status or disease history) In general, this age group constitutes around 20-25% of the total population Expected coverage: More than 90% (evaluated coverage) Regular routine immunization sessions will be conducted without interruption Two regular routine immunization clinics per week Measles catch-up campaign in remaining four days Average Campaign duration: 3 weeks = 12 working days 1st week: School based campaign (for 5-10 year children) 2nd & 3rd weeks: Community based campaign for non-school going children 13

Catch-up campaign: Basic vaccination strategy … 2/2 All immunizations from static posts (no HTH immunization) Types of session sites Session sites at Educational Institutes: All types of schools where <10 years children attend will be used as vaccination sites. These sites will be covered in the first week of the campaign. Outreach site (regular RI sites and additional sites in village/urban mohalla): Children who do not go to school or those left out during the vaccination week in schools will be covered from regular RI/UIP sites during the 2nd and 3rd weeks. Mobile/Special team: Street children and other high-risk populations in urban areas are most likely to have missed their routine dose in their infancy and may also miss the second opportunity. Facility based session site (Fixed sites): All health facilities at PHC level and above will function as session sites throughout the campaign duration 14

Why Schools are Important School Campaign in 1st week: “Make or Break” for rest of the campaign Since schools will cover around half of the target children, the success of this campaign will depend largely on the full support, commitment and ownership of the education sector. If properly planned, large number of children can be vaccinated with lesser effort and duration than community campaign 15

School Sites & Teams Vaccination sites at all educational institutes where <10 years children attend Government and private schools, crèches, day-care centers, Madrassa Complete the vaccination in a school in one day Timing: As per school timing; match with school shifts. Extra vaccinators for Urban wards as higher number of schools Temporary skilled-vaccinators (nurses, intern doctors, private doctors, senior nursing students etc.)

Planning Enlist all schools in the PHC area, using Form-3 Number of vaccinators to cover a school in one day = Target population/200. Vaccination team: Generally a vaccination team will have 1 trained vaccinator (ANM / Others) * 1 ASHA /Link worker or similar staff (for urban areas) 1 AWW 1 volunteer * In case the beneficiary load is 150-300 at one outreach site or 200-400 at one school site, the team will have two vaccinators.

Role of Schools Organize measles vaccination centre inside the school Identify a nodal person from the school who will Provide space in the school Mobilize and control the flow of children. Identify teachers as volunteers systematic queue management, mark tally sheets / marking fingers of children Mobilize school teachers to support vaccination teams. Send prior intimation to parents of school children regarding day of measles immunization at the school and seek their cooperation.

Role of Schools To train teachers to teach school children and parents about Benefit of measles immunization in connection with child health Inform about the date, time and place of vaccination. To encourage children to educate/share information with their parents on Importance of measles immunization Date, time and vaccination site for younger siblings (children less than 5 years in the family)

Team of Expert doctors for AEFI -120 with AEFI Kit Role of Schools Injection Safety & Waste management plan Teams should not leave any waste at the school site. AEFI Management Assist the vaccination team in case of emergency Provide transportation if required Allay concerns of students and parents Team of Expert doctors for AEFI -120 with AEFI Kit Not a single case of serious AEFI from – 655921 injection in Patna District

Impact

Assessing the impact of campaigns MCUP-States having measles surveillance Phase -1 catch-up campaign dates 1 year pre Phase 1 MCUP* 1 year post Phase 1 MCUP Total number confirmed measles outbreaks Total number of confirmed measles cases Total number of confirmed measles outbreaks Gujarat Mar 11-Jul 11 18 660 Madhya Pradesh Dec 10-Jan 11 8 613 Rajasthan Nov 10-Dec 10 4 211 2 54 Grand Total 30 1,484 Note: Surveillance not implemented until after the campaigns; Data updated as on 4th March 2012 * Approximately 1 year before start of Phase 1 activity including the campaign months No. of lab confirmed measles outbreaks reduced significantly after the MCUP as evidenced from surveillance data from phase-1 districts in 3 measles surveillance states.

Bihar: Signs of campaign impact 2012 Surveillance results: Lab confirmed measles outbreaks = 19 Total cases = 1089; Deaths = 8 48% unvaccinated 82% < 10 years of age N=(1089) 41% 36% 11% 7% 6% MCUP phase 1 Dec 2010-Jan 2011 MCUP phase 2 Nov 2011-Feb 2012 19 Lab confirmed measles outbreaks 1 Lab confirmed rubella outbreaks 9 Lab confirmed outbreaks negative for both measles & rubella As on wk - 35

Bihar: Signs of campaign impact 2011 Surveillance results: Lab confirmed measles outbreaks = 21 Total cases = 2527; Deaths = 16 72% unvaccinated 85% < 10 years of age N=(2527) 42% 37% MCUP phase 1 Dec 2010-Jan 2011 MCUP phase 2 Nov 2011-Feb 2012 11% 6% 8% 21 Lab confirmed measles outbreaks 2 Lab confirmed rubella outbreaks 6 Lab confirmed outbreaks negative for both measles & rubella As on wk - 35

Block Wise Achievement Report of Measles Campaign of Patna Rural (03.12.2012 - 16.12.2012)

Block Wise Achievement Report of Measles Campaign of Patna Urban (03.12.2012 - 16.12.2012)

Example of a well organized school campaign

Queue with vaccination card

Vaccination & Position of child by teachers/staff

Make the measles campaign a big event in the district.

Proper queuing for efficient time management School activity takes less time as waiting time of vaccinators is almost nil. So a load of 200 is doable. Proper queuing for efficient time management

Table 1: Well planned site. Note Immunization Cards on table

Table 2 for Vaccination: Noting the time of reconstitution on the vial

Table 2: Correct Procedure AD syringe / No touching of the needle or hub / 450 angle for subcutaneous injection

Table 3: Waste Disposal

Table 3: Hub Cutter in use

Table 4: Filling up the Tally sheet

Inj. Adrenaline Table 5: AEFI Kit

Waiting at least 30 minutes after the injection.

Everybody has an Immunization Card

MCUP- Urban Schools Details

For Any Quarry / Support Please contact to :- 1- Dr. Lakhinder Prasad, Civil Surgeon - Patna (Mob.-09470003600) 2- Dr. S.P. Vinayak, District Immunization Officer - Patna (Mob.-09470003548) 3- Dr. Rajesh Kumar Verma SMO, Patna, Mobile – 09771496458 email – addsmopatna@npsuindia.org

Thanks