September 29, 2010

MSF physician Cameron Bopp returned in July after several months in Africa. Here, he discusses his time in Malawi, during which he was tasked with overseeing the emergency response to the measles outbreak and setting up vaccination programs.

Malawi 2010 © Nabila Kram

MSF staff vaccinate children against measles in the city of Blantyre.

A veteran family physician with numerous Doctors Without Borders/Medecins Sans Frontieres (MSF) missions under his belt, Dr. Cameron Bopp returned in July after several months in Africa. He served first as medical team leader in Chad and then as emergency coordinator in Malawi, which was in the midst of a widespread measles outbreak-one of several to hit the region in recent years after two decades of steadily decreasing case numbers. Here he discusses his time in Malawi, during which he was tasked with overseeing the emergency response to the measles outbreak and setting up vaccination programs.

Planning the Intervention

Our original targets were the city of Blantyre, which was the epicenter for the Malawi measles outbreak in the south, followed by Chiradzulu, which also had a very high rate and is the home base for an MSF HlV/AIDS treatment program, and Mzimba, in the north, which had a fairly high attack rate as well.

But the window for trying to control the epidemic by responding early in Blantyre was closing. It took about six weeks from the time we made the original proposal to the time the Ministry of Health gave us permission to start the vaccination program. By then, it was rapidly spreading to the adjacent districts. So plans started being made for Lilongwe, the capital, which was coming on the screen.

Our strategy turned out to be perfect, in retrospect, I think. We vaccinated the three major urban areas in the country - Blantyre, Lilongwe, and Mzuzu, which is the regional capital in the north. They were also the places that, along with Chiradzulu, had the highest attack rates at the time we vaccinated.

On the Upsurge of Outbreaks

There's going to be a lot of research done to explain this, but at this point, I think some of the big factors in Malawi are HIV, which increases the number of people who are susceptible to the disease, and the fact that, from what we were able to see from the government campaigns, protocols for cold chain and supervision of vaccinators weren't really in place. This probably leads to people who on paper have been vaccinated but who aren't really getting effective vaccinations. And I think a third thing is that after 10 or 20 years, the protection of previous vaccinations can start to wear off. Probably those three factors put together are accounting for what we're seeing.

It was an eye opener for younger health care workers who'd never seen measles, who were misdiagnosing it, essentially, because they hadn't seen it- the same way I did when I came across my first measles case. These were people in their early 20s, young nurses, med ical assistants, and clinical officers. There were no real national protocols in place for measles outbreaks. There were also a lot of gaps in medications. So the initial case management was very satisfying because a little bit of teaching and the drug kits go a long way, both for better surveillance and better case management.

Who Contracted Measles

There were a lot more adults than usual in this epidemic. In Blantyre, which has the [country's] highest HIV rate, adults represented one-third of all patients. After the vaccinations, the people who continued to come in with measles-because they weren't vaccinated- were adults. And of them, at least of those hospitalized, a high percentage was HIV-positive.

Otherwise, it followed the usual patterns. The attack rates were highest in children aged 6 to 8 months and 9 to 11 months. But the number of cases in children aged 5 to 15 years was high enough that you had to vaccinate that entire cohort to achieve control.

Initially, people were coming in very late. In rhe early stages of any epidemic, when the population isn't aware that there's a serious outbreak going on, people come in in the late stages of pneumonia, the late stages of dehydration from diarrhea, later in the course of clinical presentation. That's why the death rate is usually higher initially.

I'm not sure I'd say people were panicked, but there was certainly a lot of fear. I think that's why we had such an enormously successful campaign. The social mobilization was almost the easy part, though you can never take that for granted because it's too important. There was remarkably little national press coverage of the measles epidemic initially, but word did spread through local networks.

On the Role of the Emergency Coordinator

The role evolves as the project evolves. Initially, it's concentrated on set up and strategy, going in and opening a project. Once the teams are in, you've done the initial training, and you've made sure that the program is up and running, you switch to fine tuning.

You try to allow yourself time to look at the big picture, to look at the data, and make sure that things are happening the way they're supposed to.

You know it's going well when your epidemic curves really start coming down. Initially, you look at your estimated vaccination coverage rates on a daily basis. You look at the consumption of needles and syringes and vaccines to make sure everything lines up, that there are no red flags. You want to make sure you don't run out of supplies. But the big number is The percentage of people in each target group that you're vaccinating.

In Malawi, it was totally rewarding because we were doing 105 percent, 110 percent, 115 percent, wherever we were. That was partly because the census numbers were probably a bit behind, partly because we had people coming in from other districts to be vaccinated.

The number of cases in the country was up to 33,000 the week I left, but it's still a fairly small percentage of the population that gets measles. It's not like there's mass panic going on. It's different than a meningitis campaign, where the mortality rate is pretty high and people are more afraid. In this, you really wouldn't know from walking on the streets that there was an epidemic although it's not rare to come across someone in Blantyre who says they have lost a relative to measles.

On New Ways of Responding

MSF has been instrumental in showing that in a developing country, a measles epidemic can go on for months to well over a year. The original World Health Organization guidelines claimed that once a measles epidemic started, it was too late to do anything about it, and in terms of vaccinating you have to let it run its course. That was dead wrong. [Editor's note: In 2006, MSF released a study that showed that rapid, wide-scale vaccination programs can reduce the toll inflicted by measles outbreaks even after they've begun, and the WHO has since changed their guidelines to reflect this.] And that's one of the rewarding things about being a part of an organization like MSF: You know that your data is going to be put to use. It's going to become part of a broader database that can lead to some clinical research, some epidemiological research that can help improve international policies.

Looking Back

The two images that come to mind are, first of all, the epidemic curves, when we really started seeing the numbers go down and the joy that brought to the team and the Ministry of Health and everyone else. And the other thing is the enthusiasm and dedication of the expat teams, especially the first mission people. I told people when they came, “You can't have a better first mission than a vaccination campaign. It's short, it's intense, but everybody has exactly the same goal in mind no matter what their piece is. And it's really nice to be part of a group that shares something so intimately.”

The two expat teams performed fantastically, vaccinating 2.1 million children over a period of two months. We had challenges, but people rose to those challenges. They learned how to do problem solving daily, hourly, whatever was needed. There's no way to overestimate how important experience is. It's something that just can't be taught. You learn it from people who have more experience than you and then ultimately you learn it wit h on-the-job training, being put in this position, having some successes and some mistakes, trying to learn from both and apply them better next time.

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