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

2. 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

3. Disproportionate burden of measles mortality in India
India: 60, ,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

4. 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

5. 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

6. 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%)

7. 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.

8. 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%)

9. 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

10. ….Benefit after measles vaccination
Bullet points
Bullet Points

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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.)

17. 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 at one outreach site or at one school site, the team will have two vaccinators.

18. 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.

19. 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)

20. 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 – injection in Patna District

21. Impact

22. 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.

23. 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

24. 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

25. Block Wise Achievement Report of Measles Campaign of Patna Rural
( )

26. Block Wise Achievement Report of Measles Campaign of Patna Urban
( )

27. Example of a well organized school campaign

28. Queue with vaccination card

29. Vaccination & Position of child by teachers/staff

30. Make the measles campaign a big event in the district.

31. 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

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

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

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

35. Table 3: Waste Disposal

36. Table 3: Hub Cutter in use

37. Table 4: Filling up the Tally sheet

38. Inj. Adrenaline
Table 5: AEFI Kit

39. Waiting at least 30 minutes after the injection.

40. Everybody has an Immunization Card

41. MCUP- Urban Schools Details

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

43. Thanks