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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 108-113

External rapid convenience monitoring of measles–rubella campaign 2017 and lessons learned: Study from a hilly district of North India


1 Department of Community Medicine, Dr RKGMC, Hamirpur, Himachal Pradesh, India
2 Department of Community Medicine, IGMC, Shimla, Himachal Pradesh, India

Date of Submission18-Feb-2020
Date of Decision19-Jun-2020
Date of Acceptance10-Oct-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Dr. Vijay Kumar Barwal
Department of Community Medicine, IGMC, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCFM.IJCFM_17_20

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  Abstract 

Introduction: The most recent vaccine incorporated in the Universal Immunization Program of India is measles-rubella vaccine, introduced as a catch-up campaign to eliminate measles and control rubella by the year 2020. The success of any immunization campaign lies on its meticulous planning for areas such as trainings, cold chain management, advocacy, and social mobilizations. Rapid convenience monitoring (RCM) was done in nine health blocks of a hilly district of Himachal Pradesh, pertaining to various campaign activities, for determining vaccine coverage and side effects.
Material and Methods: Standardized formats developed by the World Health Organization for RCM of the quality of activity at session sites which included information regarding vaccinating teams, immunization sites, logistics used, cold chain and aseptic condition management, waste disposal, and record maintenance were used. School and house-to-house visits were conducted randomly to check the indelible ink mark/vaccination cards to find out any missed child.
Results: A total of 107 immunization sessions were observed for compliance. We assessed 1182 children between the age group of 9 months and 15 years for determining vaccine coverage during the measles–rubella campaign in September–October 2017. Compliance to various aspects of the campaign was found very good, exceeding 90% in almost all the domains. The total vaccination coverage was 98.1%. Schools and health-care providers were the major source of information for this campaign. No severe adverse events following immunization were reported during the survey.
Conclusion: Activity compliance and vaccination coverage were found high. Adequate supply of indelible ink pens and functional hub cutters needs to be ensured. There should be revision of incentives to team members with increased involvement of accredited social health activist workers in such campaigns.

Keywords: Measles–rubella campaign, measles–rubella vaccine, rapid convenience monitoring, vaccination coverage


How to cite this article:
Kumar D, Barwal VK, Sachdeva A, Gupta A. External rapid convenience monitoring of measles–rubella campaign 2017 and lessons learned: Study from a hilly district of North India. Indian J Community Fam Med 2020;6:108-13

How to cite this URL:
Kumar D, Barwal VK, Sachdeva A, Gupta A. External rapid convenience monitoring of measles–rubella campaign 2017 and lessons learned: Study from a hilly district of North India. Indian J Community Fam Med [serial online] 2020 [cited 2021 Apr 19];6:108-13. Available from: https://www.ijcfm.org/text.asp?2020/6/2/108/304790


  Introduction Top


The most recent addition to the India's Universal Immunization Program is the combined measles–rubella (MR) vaccine introduced as a catch-up campaign.[1] Compared to the routine immunization (RI), such campaigns have many technical and operational issues. The major challenges faced are a huge target group to vaccinate, requirement of a large pool of trained vaccinators, and giving an injectable vaccine in schools and outreach sessions.[2] During the previous rounds of MR campaign in other states, it was found that training of health workers, the timing of campaign, inadequate social mobilizers and vaccinators, inadequate and incomplete micro-planning, and overall human resource and logistic constraints were the limiting factors.[3],[4]

Therefore, the success of any immunization campaign lies on its meticulous planning such as trainings, logistics, cold chain management, advocacy, and social mobilizations. Monitoring of these activities during the campaign by internal and external observers is essential to identify any constraints that are likely to affect the implementation of the program. Their feedbacks provide valuable inputs and solutions to remove any bottlenecks and provide future recommendations.[2],[3],[4],[5]

Himachal Pradesh along with seven other states conducted this MR campaign from August to October 2017.[6] At the request of the World Health Organization (WHO) state surveillance office, external monitoring of this campaign was done by the Department of Community Medicine, Indira Gandhi Medical College, Shimla. The process of external monitoring itself provides an opportunity to assess as well as support in the field. Hence, accordingly, we planned this study to assess the immunization sessions and determine the vaccine coverage. We also wanted to identify and disseminate the barriers, and give suggestions to help in better vaccination coverage in the subsequent phase as well as in other campaigns.


  Material and Methods Top


MR campaign was conducted in Himachal Pradesh for 5 weeks with effect from August 30, 2017 to October 3, 2017. Three specialists from the community medicine department were deputed for monitoring of immunization sessions and assess coverage of the campaign. The checklist used was standardized formats developed by the WHO for rapid convenience monitoring (RCM) of the quality of activity in an area.[4] External monitors were briefed about the methodology of monitoring (RCM) by the WHO surveillance medical officer before the start of the campaign. The checklist included information regarding vaccinating teams, immunization sites, logistics used, cold chain and aseptic condition management, waste disposal, and record maintenance. Prior approval for conducting the study was taken from the institutional ethics committee of Indira Gandhi Medical College, Shimla. Informed consent/assent was taken from all the participants, and confidentiality of all the participants was ensured. We conformed to all the ethical guidelines as per the Helsinki declaration.

All the nine health blocks of Shimla district were visited by the external monitors. There were an estimated 189,030 children (between 9 months and 15 years of age) eligible for vaccination in Shimla district. A total of 1752 sessions were planned which included 1135 schools, 480 outreach, 113 fixed, and 24 high-risk areas. Mobilization of children was ensured through information, education, and communication activities via mass media. Awareness messages were relayed through radio, television, local cable networks, newspapers, posters, banners, and miking at periodic intervals. Community-level workers such as accredited social health activists (ASHA), anganwadis, auxiliary nurse midwives, and school staff were also looped in for delivering sensitization talks in the schools. Data collection was done concurrently to the immunization campaign. The RCM coincided with the immunization sessions in schools and outreach sites.

During the first 2 weeks, RCM was done in schools, followed by monitoring of outreach sessions in the next week, and house-to-house visits were conducted in the last 2 weeks. In schools, the children were assessed by physical verification for presence of the indelible ink mark. A child was considered unvaccinated if the mark was absent. During household visits on regular school days, their vaccination status was assessed indirectly through the inspection of vaccination cards. Both the school/outreach site and household survey was conducted in different geographical areas to prevent overlapping or duplication of effort. The number of children covered and left out was noted. Due to logistic and managerial issues, it was very difficult to conduct repeat school or outreach sessions, so the parents of left-out children were requested to take their children to the nearest fixed site/hospital for vaccination. There was a maximum gap of 1 week between vaccination and assessment of vaccination coverage in the field or schools.

The schoolchildren and teachers/principals were also asked about the feedback or constructive suggestions, in case a similar activity has to be undertaken in the near future. Regarding house-to-house visits, the standard methodology of selecting the households, that is, going to the center of the village, rotating a pen, and then starting from the first house which the pen tip pointed, was followed. The house visits were done till we managed to cover twenty children in each village in rural areas, or a ward in urban areas. The members of the family were also asked about the sources of information about the campaign and the side effects encountered after vaccination.

The aforesaid methodology ensured assessment of quality and completeness of vaccine coverage. Prompt remedial action was taken for any deficiency or deviation observed. Onsite supportive supervision and hand holding of the vaccinating teams was done. The various problems such as technique of vaccination, requirement of additional teams for sudden unexpected rush of children, malfunctioning hub cutters, shortage of insulin syringes, and some teams not using the full volume of diluent for reconstitution of vials were identified during the course of monitoring and were rectified or handled appropriately.

The checklist used for RCM has eight specific domains, and each domain is represented by multiple items (44 items in all).[4] Out of the eight domains, we have left out the first and seventh, that is general information and the school-specific domain. Hence, we have presented the data of six domains which were assessed for compliance at the immunization sessions [Table 1].
Table 1: Checklist used for rapid convenience monitoring (RCM)

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Activity compliance, vaccine coverage, and side effects were expressed in frequency proportion tables. Regular inputs and feedbacks were collected by the external monitors throughout the campaign and these inputs have been categorized according to various activity domains.


  Results Top


A total of 107 different immunization sessions were monitored for compliance during the campaign. Compliance regarding different domains was in excess of 90% except for injection practices which were found adequate at 88.8% of the session sites observed. Compliance for safe injection practice during the campaign was only 70% at health facilities [Table 2].
Table 2: Compliance to various aspects of vaccination during the measles- rubella campaign

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A total of 1882 children (1162 at school and 720 at household level) were assessed for vaccine coverage. All children in the schools were assessed by physical verification; while out of 720 at the household level, 308 were assessed through physical verification and rest through vaccine card, 35 children were found unvaccinated during the survey, accounting for the overall vaccine coverage of 98.14% [Table 3].
Table 3: Vaccination status of children surveyed for assessing coverage

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Schools (77%) and health-care providers (72%) were the major source of information regarding MR campaign. Mass media approach such as television/radio/miking (18%) and newspaper/poster/banner (22%) were the source of information in limited population [Figure 1].
Figure 1: Source of information about the measles–rubella campaign

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Sickness during the period of MR campaign was mentioned as the most common reason (15/35) for noncompliance among the unvaccinated children. Nine unvaccinated children provided family refusal as the reason for noncompliance. Seven children avoided vaccination because of the fear of side effect of the vaccine [Figure 2].
Figure 2: Reasons for noncompliance

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Mild pain was reported by 12% of the children, while 2% had swelling at the site of injection. A few others reported excessive crying (4%), headache (4%), pain abdomen (2%), and fainting (2%) [Figure 3].
Figure 3: Pattern of side effects observed by the children after vaccination

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Feedbacks collected during the campaign are summarized in [Table 4]. Although it was generally positive except for few incidences of programmatic error and complacency at certain session sites, we have laid stress on the negative points so that it may help program managers and planners to avoid such obstacles and take care of these things in future.
Table 4: Feedbacks received during the campaign from external monitors

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  Discussion Top


RCM has been used as a primary method for monitoring mass vaccination campaigns. Its effectiveness and contribution to increasing campaign quality has been documented previously.[7]

Compliance to various aspects of vaccination campaign was found very good, exceeding 90% in almost all the domains. Adequate workforce was present in 96.3% of the session sites observed. Around 90% of the session sites were compliant with safe injection practices, proper cold chain maintenance, and Adverse Events Following Immunization (AEFI) management preparedness. Deviation of the activities from standardized guidelines was very small (<10%) in the current surveys, which indicates a successful planning and execution of the campaign.

Vaccination coverage in this survey was 98.1% for MR vaccine. Routine measles vaccination coverage reported by the National Family Health Survey-4 in Himachal Pradesh for 2015–2016 was 87.4%.[8] Bhardwaj et al. in their survey reported routine vaccination coverage of 82.7% for measles in 2016.[9] The vaccination coverage in the present study was similar to that of RCM in Nepal and Bhutan where 95% and 98.17% of children were vaccinated, respectively.[10],[11] The estimated national coverage with MR vaccine in Haiti was 79.2% in 2007–2008.[12] The high vaccination coverage reflects the strong health infrastructure and efficient health-care delivery system existing in this hilly state. Acceptance for such mass immunization campaigns involving a number of stakeholders from various sectors is quite remarkable and further solidifies the concept of intersectoral coordination.[13]

Mass campaign of a vaccine requiring an injection at sites away from health institutes always instills fear among children, parents, teachers, and even health-care providers. Despite this, noncompliance was very low in the present study and the most common reason reported was current sickness, which is acceptable and can be rectified in RI sessions. The second most common reason was refusal from family, most probably because they had already vaccinated their children with the vaccine and had feared hyperimmunization. No severe AEFI was reported during the survey. Mild side effects such as local pain and swelling were reported by 12% of the children. Other side effects such as excessive crying, headache, fainting, and fever were reported within the expected limits, which assures the safety of this vaccine.

Vaccination process especially safe injection practice and maintaining cold chain is the backbone for any campaign, which not only ensures high sero-conversion but also reduces the chance of unwanted side effects. Small mistakes or complacency was observed at certain session sites, which needs to be stressed upon during the preparedness or training stage.

Communication plays a vital role in the success of such mass campaigns, and it is important that a right message is conveyed to a right person through a right medium.[14] A lot of miscommunications or misinterpretations tend to arise in such situations, which has to be addressed in the preplanning period as well as during the ongoing activities. Schools and health-care providers were the major source of information for this campaign. Mass media had limited role as a primary source of information in this campaign, which can be utilized in a better way in the near future. Higher enrollment of children in schools and a large pool of health workers had been utilized effectively.

Another important aspect of the campaign was record maintenance and fluent data flow from ground level to higher authority. Complacency has been observed at certain points that necessitates the role of strict vigilance and supervision.

Dedication of the vaccinating teams is quite evident from the very high compliance rate and vaccination coverage. At present, in low- and middle-income countries, a number of public health interventions are being carried out regularly in the form of campaigns. Hence, in order to keep them motivated, their hard work needs to be appreciated. Better incentives and recognition for their work are recommended at various platforms.


  Conclusion Top


During this RCM, important feedbacks were collected from the children, vaccinating teams, teachers, parents, and external monitors. Overall, a positive feedback was received regarding the conduct of the campaign. However, few instances of programmatic error and complacency were also noticed. A few such as inadequate supplies of indelible ink pens and functional hub cutters have already been documented in literature. During the training of vaccinators, emphasis has to be laid on the importance of using the full amount of diluents.

The male health workers who otherwise do not take part in RI sessions need to be given refresher training regarding the correct immunization technique before holding such campaigns. There should also be revision of incentives for the vaccinating teams along with more involvement of ASHA workers in such campaigns in future. Similar studies in other states are advised, which will shed more light on region-specific issues. This activity has reinforced the role of strict monitoring and supervision. In the long run, it will help program managers and planners to avoid such hindrances and help in smooth running of such campaigns.

Financial support and sponsorship

We acknowledge the support of WHO State Surveillance Medical Officer, Dr. Devender Singh Tomar for providing vehicles and logistics during the tours for monitoring in the field.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
World Health Organization, Regional office for South-East Asia. Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region 2014–2020. Available from: http://www.searo.who.int/immunization/documents/sear_mr_strategic_plan_2014_2020.pdf. [Last accessed on 2019 Jan 25].  Back to cited text no. 1
    
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Measles Catch-Up Immunization. Campaign Guidelines for Planning and Implementation. Ministry of Health and Family Welfare Government of India. June; 2010. Available from: http://www.nihfw.org/pdf/Measles%20SIA%20Guidelines%20India%20_Final_Foreword_ver3.pdf. [Last accessed on 2020 Jun 24].  Back to cited text no. 2
    
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Hyde TB, Dentz H, Wang SA, Burchett HE, Mounier-Jack S, Mantel CF, et al. The impact of new vaccine introduction on immunization and health systems: A review of the published literature. Vaccine 2012;30:6347-58.  Back to cited text no. 3
    
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Introduction of Measles Rubella Vaccination (Campaign and Routine Immunisation). National Operational Guidelines 2017. Ministry of Health and Family Welfare, Government of India. Available from: http://www.searo.who.int/india/topics/measles/measles_rubella_vaccine_guidelines.pdf?ua=1. [Last accessed on 2019 Feb 15].  Back to cited text no. 4
    
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Measles-Rubella Vaccine Campaign to Cover 18.6 Lakh Children in HP. Deccan Herald; 2017. Available from: http://www.deccanherald.com/content/628883/measles-rubella-vaccine-campaign-cover.html. [Last accessed on 2019 Mar 21].  Back to cited text no. 6
    
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Luman ET, Cairns KL, Perry R, Dietz V, Gittelman D. Use and Abuse of Rapid Monitoring to Assess Coverage During Mass Vaccination Campaigns WHO. Available from: http://www.who.int/bulletin/volumes/85/9/07-045328/en/. [Last accessed on 2019 Apr 26].  Back to cited text no. 7
    
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State Fact Sheet Himachal Pradesh. District Level Household and Facility Survey-4. Ministry of Health and Family Welfare. Available from: http://rchiips.org/pdf/dlhs4/report/HP.pdf. [Last accessed on 2019 Apr 26].  Back to cited text no. 8
    
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Bhardwaj AK, Kumar D, Sharma S, Gupta A, Chander V, Sood A. Building Evidence for Coverage of Fully Vaccinated Children of 12-23 Months of Age across Districts of North India, 2015. Indian J Community Med 2017;42:197-9.  Back to cited text no. 9
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Rainey JJ, Danovaro-Holliday MC, Magloire R, Kananda G, Lee CE, Chamouillet H, et al. Haiti 2007-2008 national measles-rubella vaccination campaign: Implications for rubella elimination. J Infect Dis 2011;204 Suppl 2:S616-21.  Back to cited text no. 12
    
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