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).
Public Health Update is a popular public health portal in Nepal. It was initiated in 2011. The main purpose of this platform is to share public health updates, information & opportunities for public health professionals all around the world. Thousands of health professionals have trusted Public Health Update as the right website to find the latest public health opportunities, information & resources for health updates in Nepal. It is expected that this initiation will help public health professionals to have access to the right information & opportunities at the right time to develop their professional careers. Public Health Update is committed & dedicated to deliver accurately, trusted, up-to-date health information & opportunities to all health professionals. The most popular information in this blog are jobs, scholarships, conferences, fellowships, awards, internships, grants, national & international plan policy, guidelines, reports, and health news. If you have any complaints, information, or suggestions about the content published on Public Health Update, please feel free to contact at [email protected]. Thanks for visiting us. Public Health Update: Inform | Advocate | Promote | Motivate | We are globally connected.
Public Health Update (Sagun’s Blog) is a popular public health portal in Nepal. Thousands of health professionals are connected with Public Health Update to get up-to-date public health updates, search for jobs, and explore opportunities. #1 Public Health Blog for sharing Job opportunities and updates in Nepal
”Public Health Information For All” – – Sagun Paudel, Founder
