1. Measles Catch-up Campaign Bangladesh & Pakistan Quamrul Hasan WHO - Pakistan

2. Bangladesh Division: 6 District: 64 Sub district: 463 Union council: 4,451 City Corporation: 6 Municipality: 223 Area: 153,378 sq km Population: 140 million Population density: 1,045/Km 2 Bangladesh Division: 6 District: 64 Sub district: 463 Union council: 4,451 City Corporation: 6 Municipality: 223 Area: 153,378 sq km Population: 140 million Population density: 1,045/Km 2 Sylhet Chittagong Dhaka Barisal Rajshahi Khulna Pakistan Province: 4 & AJK District: 134 Sub district: 474 Union council: 6,806 Area: 803,940 km 2 Population: 176 million Population density: 206/km 2 Pakistan Province: 4 & AJK District: 134 Sub district: 474 Union council: 6,806 Area: 803,940 km 2 Population: 176 million Population density: 206/km 2

3. Phase 1 (01-18 March 07) 4 districts Phase 2 (02-18 July 07) 6 districts Phase 3A (20 Aug to 5 Sep 07) 28 districts Phase 3B (27 Aug – 12 Sep 07) 12 districts Phase 4 (12-28 Nov 07) 48 districts Phase 5 (17 March- 02 April 08) 35 districts Phase 1 (03-22 Sep 05) 2 districts + 1 City Phase 2 (25 Feb-16 March 06) 62 districts + 5 City

4. Campaign Target & Achievement PakistanBangladesh Target agePhase 1: 09 months to less than 15 yrs Phase 2 to 5: 09 months to less than 13 yrs 09 months to less than 10 yrs Phase wise target & achievement (administrative data) TargetAchievementCoverageTargetAchievementCoverage Phase 12,571,5362,511,83798%1,481,3211,374,39093% Phase 21,219,3641,282,232105%34,199,59034,637,764101% Phase 36,890,6036,906,376100% Phase 421,262,96020,566,49797% Phase 534,123,30535,315,375103% Total66,076,76866,582,317101%35,680,91136,012,154101% Independent assessment 96% (Independent survey of phase 5 by education department with WHO assistance) 92% (RCA by independent local and international monitors)

5. Few facts & figures PakistanBangladesh Skilled person41,98652,397 Non-skilled person/volunteer64,733762,192 1 st line supervisors6,9949,505 Vaccine (doses)81 million44 million AD syringes81 million44 million Reconstitution syringes8.1 million4.4 million Safety boxes890,000484,000 Campaign duration2 to 2½ weeks3 weeks Actual campaign working days15 days (18 days in ph 1)12 days Average cost per child (approx.)US$ 0.55US$ 0.38

6. Political commitment & support Political commitment – Bangladesh: Enjoyed highest level political commitment Multi-sectoral involvement ensured – Pakistan: Phase 5 enjoyed better administrative support Local people’s representatives extended excellent support Active participation and support from education department in both countries

7. Campaign preparation and microplanning Bangladesh – About 1 year uninterrupted preparation – Head count done in each and every schools and community for accurate target setting – Repeated revision and refinement of microplan Pakistan – Short time of preparation in between repeated polio campaign rounds – School target determined by head count – Community target set by estimation from census – Microplan prepared just few weeks before campaign

8. Cold chain Government in both countries provided handsome number of additional cold chain equipments from their own resources In Pakistan, additional cold chain equipments reached country during the 4 th phase Shortage of power supply was a common challenge in both countries

9. Safe waste disposal Safety box was used to collect sharp waste in both campaign without any exception Burn and burry method was adopted in most instances in both countries Unsupervised disposal  incomplete burning during the early days of campaign

10. Routine EPI during campaign Beside measles vaccination, health facility based fixed sites provided routine EPI service daily throughout the campaign days in both countries Routine EPI is mostly outreach based in both countries – Bangladesh: went uninterrupted according to annual microplan – Pakistan: inconsistent scenario

11. Supervision and monitoring Limited capacity of 1 st line supervisors for providing technical support to the vaccination team Use of common sense and pro-activeness missing Regular evening meeting was held to monitor daily progress

12. International monitors Bangladesh – 12 monitors during Phase 1 – 23 monitors during Phase 2 Pakistan – 2 monitors during Phase 3 – 3 monitors during Phase 4 – 6 monitors during Phase 5 Good number of well organized international monitors provide opportunity for mutual benefit

13. Challenges Inadequacy of data – Number of schools and their students; especially non- government schools of different categories, religious schools – Accurate target – Daily progress and vaccine stock update during campaign – AEFI data Skilled manpower and their training Vaccination in private posh schools Nomadic population and other high risk group Power shortage  cold chain compromised Vaccine and logistics management Waste management Time conflict with other priority programs

14. Lessons learned

15. Preparation After setting strategy, adequate time is required: at least 1 year for Data collection regarding, Effective available human resources Cold chain inventory Exact target population in school and community by registration School exam and vacation schedule Population distribution and its ethnic and cultural diversity Local weather pattern Local important events Schedule of other important program activities Local level sensitization through advocacy among service providers, clients and other stakeholders

16. Strategy School based immunization activity is easy if teachers, guardians and authorities are taken on board in advance Outreach center based immunization program is acceptable to the community Shifting center in a larger community rises access and acceptability On average vaccinating 150 – 200 children daily is an easy target for a skilled vaccinator

17. Political commitment, Leadership and Team spirit Highest level political commitment makes challenges easy Dynamic and effective leadership from government is crucial Political and top level administrative involvement may require for access to posh private schools Team spirit among the partners is the essence for micromanagement

18. Microplanning Factual microplanning is the key to success All relevant data to be ready beforehand Actual site wise target Inventory of resources, Manpower Cold chain equipments Transport Social and operational mapping Microplanning to be reviewed and refined repeatedly for fine adjustment

19. Training Maintaining quality and consistency is difficult in multiple tire cascade training Using pool of provincial/regional master trainer may give better result

20. Supervision & monitoring Medical doctors were the best choice as 1 st line supervisor Responsible Enthusiastic Earned confidence among the team and the community Daily evening review meeting helped in Identification and correction of problem Monitoring performance

21. Community participation There are high demand for vaccination among the parents Lack of awareness among community about benefits of vaccination is a false statement Refusal is not a major issue

23. Teachers and students are great partners in child health Education department can play a vital role in promoting child health activities – Through participating – Creating community awareness – Building trust

24. Vaccine & logistics management Separate logistics unit for proper vaccine and logistics management A full time consultant may lead the unit Separate storage facility for campaign vaccine and logistics Instead of hiring individual transportation, transport firm with good capacity can be hired Contingency plan for on road ice pack change Pre arrangement of traffic clearance at ferry terminal, city entry etc. Continuous monitoring of all transporters from a central control unit up to the terminal delivery level

25. Local initiative Innovative idea adopted for creating public awareness Essay competition, letter writing competition, sms competition etc. among school children Distributing hand note on measles campaign during polio NID Polio vaccine was given along with measles vaccine in previously inaccessible areas

26. Social mobilization and communication Top level advocacy for appropriate sensitization Social mobilization by school teachers and community/religious leaders gives good return at grass root level Mosque announcement most effective House to house visit important School students: good message disseminator Scope of taking advantage of nationwide media coverage is limited in multi-phased campaign Appropriate material used in appropriate place  best result

27. Selection of vaccine and syringes Avoid using vaccine from multiple manufacturer for a single phase of campaign AD syringes which are locked at 0.5 ml point are better choice Plunger stops at 0.5 ml mark. Easy to use in campaign. Plunger goes beyond 0.5 ml mark. Needs more skill for dose adjustment and prone to high vaccine wastage.

28. Recommendations for vaccine package and labeling Dark color vials are preferred option than transparent vials for protection from sunlight Both the vaccine vial and diluent ampoule label to be of similar color and graphic design Same name (either manufacturer or trade name) to be printed on both vaccine vial and diluent label using same font type and size Packing of vaccine vial and diluent must have same number of vials and ampoules