Recommendations of Measles Outbreaks and Root Cause Analysis 2022-23

Overview

The measles outbreak investigation, outbreak response immunization (ORI), and root cause analysis (RCS) of the measles outbreak were conducted in 10 districts: Banke, Morang, Bajura, Kailali, Surkhet, Bardiya, Dang, Mahottari, Kanchanpur, and Sunsari. The Root Cause Analysis of the Measles Outbreak 2022-2023 identified many key programmatic areas to improve to accelerate the MR elimination goal of 2026. This is the first study Nepal has ever done to understand the real root cause analysis (RCA) of a measles outbreak. The administrative measles coverage data, measles rubella annual country report-2023, cohort of missed children in the last five years (2017-2022), findings of independent monitoring data, and RCA desk and field findings provided sufficient evidence to support the conclusion of failure to vaccinate as the prime cause of the measles outbreak in all ten measles outbreak districts.

Summary of RCA field observation and findings:

Provider-based reasons for failure to vaccinate

• Three percentage (3%) Zero dose and 11% missed children were identified. (Max. Banke, Kanchanpur)
• Microplanning: 54% HF only had updated & included high-risk areas (Mahottari 19%)
• Knowledge gap: 79% HF know delayed schedule, 30% HF did not know maximum age limit of MR vaccination
• Immunization monitoring chart used in 50% of HFs
• Logistics: 23% HF faced shortage of vaccines & syringes; 38% shortage of registers/recording tools
• Immunization sessions: Most of the outreach sessions run in open space or poor infrastructures, 48% HF had not run regular monthly sessions due to festival, election, HWs busy in other health programs, HR shortage
• Defaulter tracking system: 29% HF fails to track

Client-based reasons for failure to vaccinate

• Vaccine hesitancy was found among specific pocket areas in Banke, Mahottari and Bardiya districts.
• Inadequate information on vaccination session sites, date and timing leading to missed RI doses
• Seasonal migrations to different municipalities, districts, or countries.
• Unaware of importance and need of vaccination and missed doses
• Fear of work or wages loss among daily wage earners

Provider-based reasons for vaccine failure

Provider-based reasons for vaccine failure indicates issues with cold chain management at the local levels

• Poorly maintained district cold room and vaccine sub-stores (vaccine are not stored in proper shelves in refrigerators)
• Outreach sessions being conducted in open space and/ or in site with poor facilities
• No back up plan or alternate energy source available for electricity cutoff in vaccine sub stores.
• Conditioned icepacks were not changed regularly at HF level during routine immunization sessions.
• Temperature monitoring not conducted regularly due to lack freeze tags, reporting forms and knowledge
• Vaccines stored beyond discard point (VVM stage III) in the refrigerators.
• Limited number of vaccine sub-stores available with skilled human resources at municipality or health facility.
• Returned unopened vaccine vials status not being monitored regularly once received at DVS or VSS.

Recommendations

Measles Rubella Outbreak Investigation and response:

• Train local RRT on measles rubella outbreak investigation and response.
• Coordinate local stakeholders (school, private hospitals/clinics, medical bodies, local and religious leaders) on outbreak management and response.
• Advocate and ensure utilization of local level contingency funds for measles rubella outbreak investigation and response at all local levels.
• Conduct measles outbreak preparedness and response training in all districts so that local RRT can provide prompt measles outbreak response.
• Ensure cross border coordination, sharing of measles outbreak information and enhance suspected measles surveillance at all points of entry.

Strengthening routine Immunization:

• Update and implement micro-plan focusing on vulnerable areas with community involvement to reach zero dose and under-immunized children.
• Revision of session sites including outreach session as per population density of area and current structure.
• Develop local strategies to reach missed children (zero dose and under-vaccinated)
• Ensure regular supportive supervision with written feedback and follow-up of supervision visit.
• Update and display monitoring chart to track monthly progress on RI coverage for corrective action.
• Revision and expansion of session sites including outreach session as per current structure using local resources by municipality
• Provinces to advocate with municipality on provision of session site infrastructure/facilities.
• Advocacy with local government and stakeholders on accelerating immunization coverages.
• Cold chain management in all levels (provincial, district, sub-store).

Enhance measles and VPD surveillance:

• Expand reporting units in all municipalities based on population density and availability of health facilities- public/private institution. And provinces to circulate official letter to private hospitals to be part of the VPD reporting unit.
• Province to share update on VPD cases and immunization to municipality and health offices.
• Ensure and plan joint supervision field visit of priority reporting units and municipalities.
• For any suspected VPD cases, health facilities to inform Health office, municipality for investigation and case management.

Accountability and governance oversight:

• Advocate on MR elimination goals with Immunization Coordination Committee (ICC) to track progress on MR elimination at all levels.
• Local RRT to present measles outbreak root cause analysis (RCA) findings to District Immunization Coordination Committee (DICC) to accelerate MR elimination activities.
• Advocate with municipality on Immunization coverage and VPD surveillance sensitivity including MR elimination progress as one of the indicators of local government institutional Self- Assessment (LISA).

Related readings

• National Immunization Schedule, Nepal (Updated)
• Microplanning for immunization service delivery using the Reaching Every District (RED) strategy
• Guideline for Typhoid Vaccination Campaign 2022
• World Immunization Week 2023: The Big Catch-Up
• Revised Schedule of Fractional doses of the IPV
• 2023 COVID-19 Recovery for Routine Immunization Programs
• The National Immunization Programme
• Schedule for Missed Opportunity Vaccination in Nepal
• World Immunization Week 2021 – Vaccines bring us closer
• World Immunization Week 2020 #VaccinesWork for All
• World Immunization Week 2016: Close the immunization gap
• World Immunization Week 24-30 April 2015
• World Immunization Week 2017 #VaccinesWork
• World Immunization Week- Protected Together: #VaccinesWork!
• World Immunization Week 2022: Long Life for All
• World Immunization Week 2018 “Protected Together, #VaccinesWork”
• ”World Immunization Week, 22–27 April 2013”
• Immunization Agenda 2030: A global strategy to leave no one behind
• Sub-National Immunization Day- 2015
• National Immunization Schedule Archives | Public Health Update
• Immunization Archives | Public Health Update
• World Immunization Week Archives | Public Health Update
• National Immunization Programme Measles Rubella Campaign