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1 figure, 2 tables omitted
The Darfur region of Sudan, composed of three states with a population
of approximately six million, has experienced civil conflict during the previous
year, resulting in the internal displacement of approximately one million
residents and an exodus of an estimated 170,000 persons to neighboring Chad.
The conflict has left a vulnerable population with limited access to food,
health care, and other basic necessities. In addition, measles vaccination
coverage has been adversely affected; in 2003, coverage was reported to be
46%, 57%, and 77% in North, West, and South Darfur, respectively. This report
describes measles-control activities in Darfur region conducted by the Federal
Ministry of Health (FMOH) in Sudan in collaboration with the United Nations
and nongovernmental organizations (NGOs) during March-August 2004. Ongoing
measles transmission in camps for internally displaced persons (IDPs) and
neighboring communities in Darfur led to a regionwide measles vaccination
campaign targeting all children aged 9 months–15 years, resulting in
a reduction in reported measles cases. Once security is improved, ongoing
efforts to increase measles vaccine coverage will be required to eliminate
persistent susceptibility to measles in the Darfur population.
During March-April 2004, the Expanded Program on Immunization (EPI)
at FMOH received reports of measles outbreaks among displaced populations
in West and North Darfur. In response to these outbreaks, the state ministries
of health and various NGOs conducted vaccination campaigns in IDP camps and
neighboring communities, targeting children aged 9 months–5 years; these
campaigns vaccinated approximately 80,000 children. In addition, clinics were
established in IDP camps to vaccinate current and incoming residents. Despite
these measures, measles virus transmission continued to occur both within
the camps and in neighboring communities.
In early April, FMOH, the World Health Organization (WHO), and UNICEF
conducted an assessment of the feasibility of a regionwide measles vaccination
campaign in the context of lack of security, population movements, and the
approaching rainy season. State-level EPI managers reported that approximately
83% of children aged 9 months–15 years in the region were accessible.
The majority of the inaccessible areas were in West Darfur, from which much
of the population had fled to Chad. On the basis of these assessments, a measles
vaccination campaign targeting children aged 9 months–15 years was planned
in the accessible areas of the Darfur region.
Authorities hoped that the negotiations between opposing parties necessary
to permit widespread access to vaccination also might result in alleviation
of civil conflict. Donor agencies pledged resources toward campaign activities,
including renewal of the vaccine cold chain (i.e., maintaining proper vaccine
temperatures during storage and handling to preserve potency) and reestablishment
of EPI services. Because of widespread malnutrition and low poliomyelitis
vaccine coverage, polio vaccination and vitamin A supplementation for children
aged <5 years were included in the campaign.
A technical group composed of provincial health staff, NGOs, and international
partners was established for campaign planning. State- and district-level
staff participated in workshops in Khartoum during the first half of May 2004
to review campaign guidelines and develop a schedule for campaign planning.
Extensive social mobilization was undertaken through mass media and community-level
activities. In late May, training sessions were held for 6,259 vaccinators,
522 team leaders, and 206 supervisors.
A mass measles vaccination campaign was launched on June 5 in South
Darfur and on June 12 in West and North Darfur and continued for 10 days in
each state. Activities included vaccination using a combination of fixed posts
and outreach immunization teams, the use of checklists to monitor vaccination
sessions, social mobilization activities, and surveillance for adverse events
after vaccination. In addition, rapid convenience surveys were used to monitor
coverage in hard-to-reach areas. At the state level, meetings were held at
the end of each working day to review progress and address problems. Tally
sheets were used to monitor campaign coverage, and data were sent to the federal
level for compilation and analysis. Vaccination sites included 500 fixed centers,
1,088 temporary posts, and 189 mobile teams.
Approximately 93% of the accessible population and 77% of the total
target population were vaccinated during the campaign. Coverage was highest
in South Darfur, an area with limited conflict, and lowest in West Darfur,
where a substantial percentage of the population was inaccessible because
of lack of security. Officials negotiated an agreement with rebel forces,
allowing campaign staff to enter conflict areas in South Darfur, but were
unable to negotiate similar agreements in West Darfur. In addition, the start
of the rainy season limited access in parts of West Darfur.
During the measles outbreak in Darfur, WHO collaborated with FMOH and
other partners to develop a system for routine surveillance and early outbreak
detection of 12 epidemic diseases, including measles.1 Data are
compiled at the state level and transmitted to FMOH weekly. Alert thresholds
for outbreaks were agreed upon for selected diseases, and a surveillance bulletin
was developed to disseminate data to key stakeholders. During the course of
establishing surveillance in the IDP camps, three serologically confirmed
measles outbreaks were investigated retrospectively. A total of 725 measles
cases and 108 deaths were identified in outbreaks that occurred during March-June
in West and North Darfur.
Transmission of measles virus continued to be observed in Darfur after
completion of the mass campaign. Of the 89 measles patients identified during
July 10–August 6, a total of 45 (51%) were from West Darfur, 33 (37%)
from North Darfur, and 11 (12%) from South Darfur. Maintaining high-quality
surveillance is necessary for enabling early detection of and response to
outbreaks. When security improves, FMOH plans to repeat a mass campaign in
these areas; this step will be critical in protecting remaining susceptible
persons, thereby stopping transmission.
EA Elsayed, MD, N Mousa, MD, Federal Ministry of Health of Sudan. A
Dabbagh, MD, World Health Organization, Geneva, Switzerland. H El-Bushra,
MD, F Mahoney, MD, World Health Organization Eastern Mediterranean Regional
Office, Cairo, Egypt. S Haithami, MD, H El-Sakka, MD, G Sabitenelli, MD, World
Health Organization; S Agbo, MD, UNICEF, Khartoum, Sudan. R Nandy, MBBS, L
Cairns, MD, Global Immunization Div, National Immunization Program, CDC.
In October 2003, FMOH developed a comprehensive strategy for measles
mortality reduction in Sudan based on the WHO-UNICEF campaign.2 The
strategy includes increasing routine measles vaccination coverage among infants,
providing a second opportunity for measles immunization, strengthening measles
surveillance, and improving case management of children with measles. The
strategy calls for a nationwide supplemental vaccination campaign for all
children aged 9 months–15 years. A pilot campaign was conducted in four
northern states in January 2004, after which plans were under way to cover
the remainder of the northern states in Sudan in late 2004. The civil conflict
in Darfur created a public health emergency, necessitating the modification
of these plans for immediate response in Darfur.
Outbreaks of measles are common among refugee and displaced populations,
and measles often is a leading cause of death in these settings.3-7 Overcrowding
increases the likelihood of infection, and young age and malnutrition are
associated with increased severity of disease.4 Consequently, measles
vaccination is a priority health intervention for areas affected by humanitarian
emergencies. The SPHERE Project guidelines,8 revised in 2004, provide
minimum standards in disaster response. These guidelines recommend measles
vaccination at the earliest opportunity for all children aged 6 months–15
years.8 Recent experience in Afghanistan suggests that large-scale
measles vaccination campaigns are possible in a country affected by conflict
and can substantially limit morbidity and mortality attributable to measles.9,10 In addition to measles control efforts in Darfur, measles vaccination
campaigns were conducted during June-August 2004 in the 10 refugee camps in
eastern Chad to which refugees from Darfur had fled. Reported vaccine coverage
in these camp-based campaigns ranged from 80% to 92%. As of August 2, these
camps housed 165,685 persons. Sixty-five percent of weekly mortality reports
and 60% of weekly morbidity reports from these camps are available for June
28–July 25 (United Nations High Commissioner for Refugees, unpublished
data, 2004); during this period, 66 measles cases and 15 measles deaths were
The high case-fatality rate (CFR) observed in Darfur and refugee camps
in neighboring Chad is consistent with studies in similar settings and emphasizes
the importance of providing measles vaccination as early as possible in such
populations. The initial response to the measles outbreaks in Darfur included
vaccination campaigns for children aged <5 years in IDP camps and surrounding
communities and the vaccination of incoming residents in these camps. Although
these efforts were important for providing protection to individual children
who were vaccinated, they had limited impact on virus transmission because
of the restricted target age group, the continuous movement of the displaced
population, and the low vaccination coverage in the surrounding communities.
The unique circumstances in Darfur presented challenges to the rapid
mobilization of a mass measles vaccination campaign. The substantial numbers
of displaced persons residing throughout broad geographic areas created a
situation in which the entire population needed to be targeted. Considerable
resources were needed to purchase vaccine, reestablish the cold chain, and
support operational aspects of the campaign. In addition, the challenging
physical environment and lack of security in the region presented formidable
logistic constraints that required extensive planning and support.
The findings in this report are subject to at least three limitations.
First, the retrospective outbreak investigations described in this report
might have resulted in incomplete ascertainment of measles cases or measles
deaths. Either of these factors could lead to an inaccurate estimate of CFRs.
Second, coverage figures for these campaigns were calculated by dividing the
total number of doses administered by the estimated target population of the
community before the conflict. No coverage surveys were conducted after these
campaigns. Finally, coverage was reported to be lowest in the insecure areas
of West Darfur. However, some of the target population might have relocated
to Chad, thus resulting in falsely low coverage estimates.
Despite low coverage in some areas, this campaign resulted in the vaccination
of approximately three quarters of the total target population and appears
to have reduced morbidity and mortality attributable to measles. This experience
demonstrates that a large-scale vaccination campaign can rapidly and successfully
be conducted in an area of conflict. However, a multisectoral approach with
commitment of all stakeholders is needed to ensure success. The future challenge
will be to ensure rebuilding of the EPI infrastructure and reestablishing
of routine vaccination services when the security situation is normalized.
The measles control activities in Darfur are funded, in part, by U.K.
Dept for International Development, European Commission Health Office, Government
of Japan, Government of Italy, U.S. Agency for International Development,
References: 10 available
Emergency Measles Control Activities—Darfur, Sudan, 2004. JAMA. 2004;292(22):2716–2718. doi:10.1001/jama.292.22.2716
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