A race against measles - and against time

18 July 2017

An emergency interrupts a preventative vaccination campaign, but the MSF team is ready! Nurse Vera blogs from the Central African Republic.
 
Vaccinating 40,000 children! This was the initial goal of our preventive vaccination campaign for children under 5 years old, in CAR, the Central African Republic.
 
But instead of 40,000 children, we ended up vaccinating 64,000. So what happened?
 
The original plan in this region, which is in the south of the country, was to vaccinate all children under 5 years old  against seven different diseases.  I wrote about all the detailed preparations we’ve been making in my last blog. Quick reminder: the vaccinations on the list were against measles, tetanus, hepatitis B, whooping cough, diphtheria, haemophilus influenza B and pneumococcus – the last two of those are possible causes of pneumonia. 
 

Vera and some of the team on a motorbike delivering vaccines in Central African Republic

Photo: Vera Schmitz / MSF

So that was the plan. But – never underestimate the unexpected! Especially when it comes to an assignment with Doctors without Borders! It’s common for the crisis regions in which Doctors without Borders are active to experience unexpected events which often require flexibility and a rapid change of plans. 

And that’s what happened here. 
 
The preparations were almost completed, the vaccination campaign was about to start, when we received the information that several children had supposedly contracted measles.
 
Measles belongs to what are sometimes referred to as the "main killers", the most common causes globally of death in childhood. Complications can be serious and deadly - especially (but not only) if risk groups such as small children or patients with an immune deficiency are infected. And it can happen to anyone who is not vaccinated.
In addition, measles is highly contagious – just a few cases can quickly lead to an epidemic of an unprecented scale. 
 

What now?
 

It quickly became clear that there was an urgent need for action. A spreading epidemic and its consequences for the population was too dangerous. Ultimately, one of the reasons why we had originally planned a vaccination campaign in the region was the low vaccination rate. Especially among the biggest population group - children under 5 years of age – the last few years of conflict has meant there have been only a few opportunities for vaccinations for this age group.
 
We evaluated our capacity and the possibility that we could intervene in this outbreak, we held discussions with the local health authorities and, finally, we received the green light!
 

The MSF land cruisers on the road in Central African Republic
Photo: Vera Schmitz / MSF
 

A new plan?

 
A race against measles - and against time.
 
Instead of vaccinating 40,000 under-5s, the new task was to vaccinate all children in the region under the age of 15 – and to do it in four weeks instead of six.
 
This meant we  wouldn need not only more vaccinations, but also more staff, more cars and  motorcycles, more syringes, more coolboxes and more of everything else – and all of that as quickly as possible!
 
Vaccination alone, however, is only one part of the intervention when it comes to fighting a  measles outbreak. At least as important is the case management of measles cases. Although there are small health posts throughout the region, there are many villages and settlements which are several hours‘ walk away. Medicines are often unavailable or not sufficient – and must normally be paid for by the patient themselves. Here, health is a luxury.
 

A tree blocks the path for the MSF team in Central African Republic
At the beginning of April we finally started. Five teams were on the road every day to vaccinate the children. Sometimes we divided the teams in half, since many settlements here consist only of a few houses and the target groups can be quite small. Another team was busy visiting the various health centres and affected villages to treat patients already suffering from measles and to distribute medicines. In this way, access to medical treatment was significantly improved and the number of complications reduced.
 

Our goal? Almost there!
 

You could almost say the way was the goal - as difficult as the journey has been. Aside from the fact that some places are only accessible by motorbike, pirogue (a kind of canoe) or even walking, we have encountered various obstacles during the course of the campaign. There are countless bridges in a precarious state, many fallen trees blocking the way, the rainy season which sometimes causes the car to get stuck in the mud ... not to mention flat tires!
 

The MSF land cruiser navigates the difficult terrain in Central African Republic

Photo: Vera Schmitz / MSF

Once on site, however, things have to move fast. The  children and mothers arrive and move in a pre-arranged circuit between different members of staff. Usually the site is protected by a fence with a narrow line functioning as an entrance to the circuit – which makes the task of crowd-control a lot easier. This means the children come one after the other, rather than all at once. Well, ideally… :-)  

 
First of all each child receives a vaccination card with the individual prescription of the vaccines – which may vary depending on the age and previously received doses.
 
This is followed by the administration of vitamin A - its prophylactic use plays an important  role, especially in regard of measles. Next step: the vaccination itself – this depends on the prescription, but for all children under five its usually the complete package of seven different antigens. All children between five and 15 years old receive the measles vaccination. Final stop is the tally sheet – each child and each vaccination, including the type and dose – is counted and ticked off.
 

A little girl proudly holds her vaccination card

Photo: Sergio Ferrer / MSF

In places where our target group was more than 500 children, instead of one circuit for all the children to follow, we established what’s known as a ‘double line‘. All the children over five years old – who we were only vaccinating against measles – went on the left side, while on the right it was all the younger children, who also received vitamin A and other vaccinations. In this way we were sometimes able to vaccinate more than 1000 children per day and site! 

It’s been a great achievement for the team, but it was only possible with good teamwork and an alarm clock ringing at 4.30am – at the latest.  Our days are long – after returning to the base at about 17h, all data needs to be gathered, entered and some final preparations for the following day to be done.
 
After one month, we’ve come to the end of the first round of the campaign, and 64,000 children aged 6 weeks to 15 years old have been vaccinated!
 
On behalf of my team, that’s quite a proud result! Soon we are launching the second round, which will be only for children under five years old.
 
Let’s do it – we are ready!
 
 
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