SUPPLEMENT ARTICLE Implementation of a Mass Measles Campaign in Central Afghanistan, December 2001 to May 2002 N. Dadgar,1 A. Ansari,1 T. Naleo,1 M. Brennan,4 P. Salama, 1 N. Sadozai,2 A. Golaz,5 F. Lievano, 4 H. Jafari,4 M. Mubarak,2 E. Hoekstra,6 A. Paganini,6 and F. Feroz3 1United Nations Children’s Fund (UNICEF) Afghanistan Country Office, 2World Health Organization Country Office, and 3The Ministry of Public Health, Islamic Transitional Government of Afghanistan, Kabul; 4Centers for Disease Control and Prevention, Atlanta, Georgia; 5UNICEF Regional Office for South Asia, Kathmandu, Nepal; 6UNICEF, New York, New York Downloaded from In Afghanistan health services have been disrupted by 23 years of conflict and 1 of 4 children die before age 5years.Measlesaccountsforanestimated35,000deathsannually.Surveillancedatashowahighproportion of measles cases (38%) among those у5yearsold.Inareaswithcomplexemergencies,measlesvaccination http://jid.oxfordjournals.org/ is recommended for those aged 6 months to 12–15 years. From December 2001 to May 2002, Afghan authorities and national and international organizations targeted 1,748,829 children aged 6 months to 12 years in five provinces in central Afghanistan for measles vaccinations. Two provinces reported coverage of 190% and two 180%. Coverage in Kabul city was 62%. A subsequent cluster survey in the city found 91% coverage (95% confidence interval [CI], 0.85–0.91) among children 6–59 months and 88% (95% CI, 0.87–0.95) among those 5–12 years old. Thus, this campaign achieved acceptable coverage despite considerable obstacles. by guest on July 28, 2015 Afghanistan, a landlocked central Asian country, shares In 2001, 8762 measles cases were reported from 328 borders with Pakistan, Iran, Turkmenistan, Uzbekistan, sites throughout Afghanistan established to conduct Tajikistan, and China. Life expectancy, estimated at 47 surveillance for acute flaccid paralysis (AFP). (AFP sur- years for women and 45 years for men [1], is among veillance monitors sensitivity of detection and accuracy the lowest in the world and 25% of children die before of reporting of suspected cases. The target is an annual their fifth birthday [2]. The population is placed at rate of 11non-polioAFPcaseper100,000children!15 about 23 million [3, 4]; however, figures are unreliable years old.) The measles cases occurred among the fol- because of large internal and external migrations. From lowing age groups: 0–4 years, 62%; 5–9 years, 29%; and 1Marchto30May2002,theUnitedNationsHigh у10 years, 9% (World Heath Organization [WHO] Commissioner for Refugees (UNHCR) estimated that Afghanistan, Kabul, surveillance data). 1,300,000 refugees returned to Afghanistan under its Few data are available for measles deaths in Afghan- voluntary repatriation program; another 200,000 re- istan. A study in Kohistan District (northeast Afghan- turned without UN assistance [5]. istan) [6] found that of 108 reported deaths from 26 November 2000 to 4 April 2001, 16% were attributed to measles and 3 occurred in children aged 5–9 years. In a joint planning document, WHO and the United Campaign funding: governments of Italy, Germany, Japan, Poland, and USA. Nations Children’s Fund (UNICEF) estimated that Reprints or correspondence: Dr. Muireann Brennan, International Emergency and given routine measles vaccine coverage of 40%, a vac- Refugee Health Branch, Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Mailstop F-48, Atlanta, GA 30333 ([email protected]). cine efficacy of 85%, and a case-fatality ratio of 5%, The Journal of Infectious Diseases 2003;187(Suppl 1):S186–90 35,000 deaths due to measles would be expected among ᮊ World Health Organization 2003. All rights reserved. The World Health Organization children !5yearsoldinAfghanistaneachyear(WHO has granted the Publisher permission for the reproduction of this article. 0022-1899/2003/18710S-0029 Afghanistan, Kabul). This figure may underestimate the S186 • JID 2003:187 (Suppl 1) • Dadgar et al. Downloaded from http://jid.oxfordjournals.org/ Figure 1. Reported measles coverage for central region of Afghanistan, December 2001–May 2002 real burden of measles deaths in Afghanistan where access to ulation 2,713,705), its 16 surrounding districts, and the prov- treatment for complications of measles is poor and children inces of Parwan, Kapisa, Logar, and Wardak (figure 1). In this 15yearsoldmayalsobeatriskformeaslesdeaths. area, health facilities were destroyed or were not functioning Concerns about a widespread measles outbreak against a because of lack of trained staff or supplies. This region has an by guest on July 28, 2015 background of low routine measles coverage, poor access to estimated 0.13 primary health care units per 10,000 population health care, and crowding among displaced persons, prompted versus 0.25 in the east and 0.03 in the south. UNICEF, WHO, and nongovernmental organization (NGO) UNICEF supports an expanded program on immunization partners, with the agreement of the Taliban and the Northern (EPI) at all levels through incentives to MoPH EPI staff and Alliance political factions, to propose a mass measles vacci- by provision of vaccines, syringes, and cold chain equipment. nation campaign. The target age group chosen was 6 months Reported routine EPI coverage among age-eligible children to 12 years, as 95% of all reported cases were in this age range. (0–11 months in 2001) was 46% for measles vaccine (range, Between June and September 2001, 11millionchildrenwere 18% in Parwan to 77% in Logar) and 47% for diphtheria- vaccinated in the most food-insecure districts. Following the tetanus toxins–pertussis coverage (UNICEF Afghanistan fall of the Taliban in November 2001, the Ministry of Public Office). Health (MoPH) of the Interim Administration of Afghanistan One EPI success was the polio eradication initiative, which (IAA) decided to relaunch the campaign, which had been in- funded much of the existing cold chain capacity in Afghanistan. terrupted by the war, and to extend it to the entire country. Despite ongoing conflict, the spring 2001 NIDs reached 872,627 This report describes the first phase of the new campaign, which (88%) of 996,253 targeted children aged 0–59 months (table was implemented in the central region of Afghanistan between 1). In addition, 83% of children aged 6–59 months received a December 2001 and May 2002. supplemental dose of vitamin A. Measles campaign planning. The campaign was planned and implemented by the MoPH with support of UNICEF, MEASLES CAMPAIGN WHO, national and international NGOs (listed after the text), Background. Data from the July 2001 polio national im- and other UN partners. All children aged 6 months to 12 years munization days (NIDs) [7] estimated the total population of were targeted to receive one dose of measles vaccine regardless the central region at 5,122,993, consisting of Kabul city (pop- of prior immunization status or history of measles disease. The Mass Measles Campaign in Central Afghanistan • JID 2003:187 (Suppl 1) • S187 Table 1. Target population and measles vaccination campaign results in central Afghanistan, December 2001 to May 2002. Target measles Vaccinated during measles campaign Vaccinated populationa NIDs aged (6 months– 6–59 months 5–12 years 6–59 b Province 12 years) Girls Boys Total Girls Boys Total All ages (%) months Kabul (city) 858,886 154,735 154,070 308,805 115,457 111,266 226,723 535,528 (62) 371,309 Kabul (districts) 198,562 44,785 46,143 90,928 25,299 26,352 51,651 142,579 (72) 141,620 Parwan 241,155 59,370 59,472 118,842 39,337 44,065 83,402 202,244 (84) 124,177 Kapisa 198,648 55,627 55,744 111,371 35,802 36,050 71,852 183,253 (92) 100,441 Logar 137,718 31,729 32,655 64,384 23,539 25,261 48,800 113,184 (82) 74,576 Wardak 113,860 29,355 29,960 59,315 21,321 22,497 43,818 103,133(91) 60,504 Total 1,748,829 375,601 378,044 753,645 260,755 265,491 526,246 1,279,891(73) 872,627 a Children in the target age group in all districts where the campaign was conducted. Data are based on spring 2001 National Immunization Day (NID) results. b Estimated proportion of children vaccinated aged 6–59 months, during 2002 spring NIDs. upper age limit of 12 years was chosen in part because of the private pharmacists, and NGO workers. A cadre of 24 expe- Downloaded from perceived difficulty in reaching children 12–15 years old who rienced health professionals or “master trainers” from all agen- might be working or refuse vaccination. Other concerns that cies was identified. These persons trained district coordinators arose during planning were that younger children might be in the provincial capitals, who in turn trained teams and su- missed owing to the logistical difficulty of targeting an extended pervisors at several sites throughout a district. age range, that girls might be harder to reach than boys for Vaccination teams, sites, record keeping. Each team had http://jid.oxfordjournals.org/ cultural reasons, and possible shortages of human resources if 5members:2vaccinators,1healtheducator,1socialmobilizer, teams were assigned to vaccinate too many children, which and 1 registrar. Sometimes a community member held each would result in poor quality implementation. child in the correct position for vaccination, which proved an The NIDs planning framework was used for the measles effective way to save time. Recording was done on tally sheets: campaign. Plans were prepared at the provincial level for each Boys and girls were tallied separately by age group. Reported district by joint MoPH, UN, and NGO teams. The district coverage by district was estimated by dividing the number of population from the July 2001 NIDs was divided by five to children vaccinated according to compiled tally sheets divided by guest on July 28, 2015 estimate one birth cohort and multiplied by 12.5, the number by the estimated target population.