Measles outbreak in a displaced persons camp with 1,200 doses and one refrigerator

Case definition. A suspected measles case is a person with fever and a generalised maculopapular rash, plus at least one of cough, coryza or conjunctivitis, with onset on or after the date the outbreak is deemed to have started in this camp. A confirmed case is a suspected case that is laboratory-confirmed (measles IgM or PCR) or epidemiologically linked to a confirmed case. For a camp with limited laboratory access, collect 5–10 ml of blood from the first 5–10 suspected cases for IgM at the state laboratory, and use the clinical definition for the rest. Record age, vaccination history, date of onset, and outcome for every case on a line list.

Immediate control measures, today.

• Isolation: keep suspected cases away from well children, especially under-fives and pregnant women. Cohort suspected cases in a separate tent or a screened area of the health post.
• Vitamin A: give two doses (on consecutive days) to every child with measles - 50,000 IU for under 6 months, 100,000 IU for 6–11 months, and 200,000 IU for 12 months and over. This reduces mortality and is the single highest-yield intervention after vaccination.
• Case management: oral rehydration for diarrhoea, zinc, antibiotics for pneumonia or ear infection, eye care, and nutritional support; refer severe cases.
• Infection control: triage at the health post entrance, hand hygiene, and masks for staff.
• Risk communication: tell the community that the campaign is coming, why, and where; counter rumours early through the camp leader and volunteers.
• Active case search: volunteers go house-to-house to find cases missed by passive reporting.

Vaccination is the priority, but these measures are what reduce deaths in the next 72 hours.

1,200 doses in 10-dose vials means 120 opened vials; the constraint is not only doses but session size and open-vial wastage. Given 6 hours of use per opened vial, sessions must be organised so that at least 10 eligible children are present per vial.

Prioritisation, in order:

1. Children aged 6–59 months, starting with those who have never been vaccinated and those living in the households and sections closest to confirmed cases. This is the group with the highest mortality, and the three deaths were in under-fives.
2. Children aged 6–8 months in the affected sections: give a dose now (for outbreak control) and a further dose at 9 months as routine.
3. Pregnant women without documented immunity, and health workers and volunteers, who are at occupational risk.
4. Children aged 5–15 years in the affected sections, if doses remain, since they are a large susceptible pool and fuel transmission.

Justification. A ring approach around cases would consume doses quickly and miss the many mild or unreported cases; in a crowded camp with 41% coverage the whole camp is effectively the transmission zone. A mass campaign for everyone tomorrow would exhaust the stock by midday and leave many children with a first dose but no capacity to complete the second round. Age-targeted, section-by-section vaccination over three days, followed by a full campaign when the 6,900 doses arrive, is more defensible.

Practical steps. Split the camp into sections, announce times in advance, use all 30 volunteers for mobilisation and 12 midwives for vaccination, and keep one team on active case search. Plan sessions to open a vial only when 10 eligible children are waiting.

Indicators.

• Process: number of children vaccinated per session and per vial opened; wastage rate (doses opened minus doses given, divided by doses opened); proportion of sessions starting on time; vaccine vial monitor status at the end of each session.
• Coverage: proportion of children aged 6–59 months in each camp section with a documented dose since the outbreak began, tracked against a camp household list.
• Surveillance: weekly suspected cases and deaths, time from rash onset to notification, proportion of suspected cases with a blood sample taken, and the line list completeness.
• Case management: proportion of measles cases receiving vitamin A, proportion with pneumonia receiving antibiotics, and case fatality rate by age group.
• Stock: doses remaining against projected need, cold chain temperature logs twice daily, and refrigerator function.

Managing the 6-hour rule.

• Open a vial only when at least 10 eligible children are present and waiting, so that the vial is finished within the session.
• Record the time each vial is opened on a labelled card attached to the vial; discard after 6 hours even if doses remain, and record the discarded doses as wastage.
• Keep opened vials in the refrigerator between batches, not on the table, and never return a vial to the fridge for use beyond the 6-hour window if the cold chain has been broken.
• Schedule sessions in the cooler hours and in areas with the highest child density, so that vials are used quickly.
• Use volunteers to pre-register children and hold them in a shaded waiting area before opening a vial.
• If wastage is high, reduce vial size by using 5-dose vials when available, or consolidate sessions across sections.

Review the wastage and coverage data at the end of each day and adjust the next day's session plan accordingly; a campaign that reports high coverage but high wastage will run out of vaccine before it reaches the children at highest risk.