Mobile screening camp with a measles cluster and a cut road
A mobile screening team is working in Union Council Kambhar, 46 km from the district headquarters, after flooding cut the metal road. Over two days the team has screened 1,150 people. Sixty-two children aged 6-59 months have a mid-upper-arm circumference below 11.5 cm; nine of them have visible severe wasting plus at least one danger sign (lethargy, inability to drink, convulsions). Three children in one hamlet of 40 households have fever and rash consistent with measles. Fourteen pregnant women report no antenatal contact at all. Stock on hand: 300 sachets of ready-to-use therapeutic food, 120 bottles of amoxicillin suspension, 40 doses of measles vaccine with cold chain assured for only 8 more hours, and 20 bags of Ringer's lactate. The team is two doctors, four paramedics and one lab technician. The road may reopen in 36 hours. Helicopter evacuation is authorised only for life-threatening cases. The district health officer expects a written report the same evening and a line list within 24 hours.
1. Set out the order in which the team should act during the first six hours, with the reasoning for that order.
Read the worked answer
Order by irreversible risk, not by headcount. First, the nine severely wasted children with danger signs: give Ringer's lactate or oral rehydration as indicated, keep them warm, and arrange helicopter evacuation for any child who is lethargic or cannot drink, because those are the only deaths likely within 36 hours. Second, the remaining 53 severe acute malnutrition cases: first dose of therapeutic food, antibiotics per protocol for those with medical complications, and enrolment with a return date, since malnutrition kills over weeks not hours.
Third, the three measles cases: isolate from the under-five queue, notify the district surveillance system immediately rather than at the end of the day, and take a line list of the 40 households. Fourth, the 14 pregnant women: register and refer to the nearest functioning antenatal point once the road opens; none is an emergency today. Fifth, general morbidity. The lab technician documents while the doctors treat, because an undocumented camp cannot be resupplied. Helicopter slots are scarce; spend them on the children who will die without them.
2. How should the 40 doses of measles vaccine be used, given that the cold chain lasts eight hours?
Read the worked answer
Forty doses is far too few for mass immunisation of the union council and enough for a targeted ring. The defensible use is ring vaccination of children aged 6-59 months in the affected hamlet of 40 households and the two nearest hamlets, prioritising under-fives with no evidence of prior vaccination, and using every dose before the cold chain fails - a wasted dose is worse than a slightly widened ring.
What I would not do is start a general campaign that runs out after 40 children, which creates false reassurance and queues without protection, or hold the doses 'for the district team'. I would also record who was vaccinated, with age and household, so the district can compute coverage later. Simultaneously I would request supplemental vaccine and a cold box from the district store and note in the report that 40 doses is a stopgap, not a response. The epidemiological argument is that measles containment depends on reaching a high share of susceptible children in the cluster, so the ring must be completed by the follow-up consignment.
3. The DHO asks for one page by tonight. What do you report, and what do you explicitly not claim?
Read the worked answer
The one-pager reports: number screened (1,150); the nine danger-sign cases with their disposition, including any evacuation request and who authorised it; the 62 severe acute malnutrition cases with enrolment figures; the three suspected measles cases with dates, ages, village and household count, flagged as suspected until confirmed; the 14 pregnant women referred; stock issued and stock remaining, expressed in days at current burn rate; and three asks - vaccine and cold box, a resupply of therapeutic food before the road opens, and a decision on the evacuation window.
I would not claim that a measles outbreak is confirmed, that the union council is covered, or that the nine children are stable. I would also not present 62 cases as the true burden: it is what two days of screening found. The line list within 24 hours should carry case definitions and a field for 'outcome unknown', because follow-up is what converts a camp report into surveillance data. Precision about uncertainty is what protects the team when the figures are challenged later.