A National Survey to Evaluate Measles-Rubella National Vaccination Campaign Coverage in Egypt

Background: A national vaccination campaign for measles and rubella (MR) was conducted in Egypt in the period from October 31 to November 21, 2015, across Egyptian governorates by the Ministry of Health and Population (MOHP), in collaboration with World Health Organization and UNICEF. It targeted 24 million children aged 9 months to 10 years. Objectives: The present survey aimed at evaluating coverage of the MR national vaccination campaign, to identify the gaps and generate sound recommendations for the upcoming campaigns. Methods: A cluster survey was conducted targeting children aged 9 months to less than 10 years. This household survey was carried out in 26 governorates of Egypt. In each governorate 240 interviews were completed. Results: The survey revealed that the campaign achieved an overall coverage of 98.2% compared to 109.8% vaccination coverage as reported by the Ministry of Health (MOH). Some clusters showed below target coverage in a couple of governorates (Port Said 93.3% and Qena 93.8%). Nonvaccinated children constituted 1.8% of all surveyed children. When causes of non-vaccination were enquired about, the most frequently mentioned cause was ignorance of parents about the vaccination campaign (43 children, 38.1%). Conclusion: The MOHP implementation of the national MR campaign was successful and achieved its objective for increased coverage with MR vaccine among the target age group.


INTRODUCTION
vident global progress has been made to reduce the impact of measles on childhood mortality, and measles cases have dramatically decreased.3) An Eastern Mediterranean vaccine action plan 2016-2020, was subsequently developed and was endorsed in October 2015 by the Regional Committee for the Eastern Mediterranean in resolution EM/RC62/R.1 as a framework for implementation of the Global Vaccine Action Plan (GVAP) in countries of the Region.The regional elimination and control targets of vaccine preventable diseases in the Eastern Mediterranean Region (EMR) include: measles elimination and interruption of endemic measles virus transmission as soon as possible, latest by 2020, as well as enhancing the introduction of rubella vaccine in EMR countries (20 countries by 2020). (4)Countries of the EMR have been implementing the regional strategy for measles elimination with variable levels of success.Based on World Health Organization-United Nations International Children's Emergency Fund (WHO-UNICEF) estimate of national vaccination coverage for 2014, coverage with the first dose of measles-containing vaccine (MCV1) was ≥95% in 11 countries, 90%-94% in 2 and 95% in 7 countries only. (5)he Region has witnessed significant progress.The number of reported measles cases decreased by around 80% between 1998 and 2014.As of 2014, eight countries reported incidence <5/million population.Measles elimination requires not only high coverage (>95%) with the vaccine but also a strong competent health system capable of reaching every child in the community. (6)Accurate and comparable data on vaccination coverage rates should be available to assess and monitor the performance of vaccination services at different national and subnational levels, to E Original Article support public health planning, allocate resources and measure the impact of interventions..2) In 2002, Egypt has established a goal of measles elimination by 2010 using the WHO/UNICEF comprehensive strategy for sustainable measles mortality reduction and set a goal of rubella elimination and Congenital Rubella Syndrome (CRS) prevention by 2010. (3)Since 2000, there has been remarkable decrease in measles cases among age groups targeted by mass vaccination.However, in 2006, dramatic increase in measles cases was reported, with outbreaks in Cairo, Giza, Beni Suef, Menia and Matrouh. (7)lobal estimates of the burden of rubella suggest that the number of infants born with CRS in 2008 exceeded 110,000 which makes rubella a leading cause of preventable congenital defects.The 2008 estimates suggest that the highest CRS burden is in the South-East Asia (approximately 48%) and African (approximately 38%) Regions. (2)Currently, 15 of the 23 countries in EMR are using rubella vaccine in their Expanded Program on Immunization (EPI) with high coverage ≥90% coverage of RCV1 and 14 of them are using a 2-dose schedule.Thirteen countries have established a national target for rubella/CRS elimination.In addition, rubella case-based surveillance is integrated with measles surveillance in all countries in the Region.Ten countries now are implementing CRS surveillance as well.In addition, the new Global Alliance for Vaccine and Immunization (GAVI) window for supporting MR catch up campaign is an excellent opportunity to intensify measles/ rubella control and elimination activities. (8)n Egypt, the burden of rubella was underestimated until 2002 when laboratory testing for rubella was implemented. (9)A median of only 24 rubella cases were reported each year during 1996-2001. (9,10)Between 2002-2004 few cases of rubella were reported.However, in 2005-2006 Egypt faced a nationwide epidemic which began in seven governorates including Alexandria, Ismailia, and Kafr Elsheikh.In which 2587 cases were reported, almost 60% of which occurred among 11-to 20-year-old children. (7,11,12)In 2012, Egypt faced an importation of measles virus from Sudan to the Red Sea and Aswan governorates, which spread then to other governorates.The root cause of the outbreak was accumulation of susceptible and immunity gaps in some risky areas.There was a gradual increase in the reported cases of measles until it reached its peak in November, 2014. (12)A national vaccination campaign for measles and rubella was conducted in Egypt in the period from October 31st to November 21st 2015, by the Ministry of Health and Population (MOHP), in collaboration with World Health Organization (WHO) and UNICEF.The campaign targeted to vaccinate 24 million children between the age of 9 months and 10 years.It was implemented across Egyptian governorates in schools, nurseries and health care facilities affiliated to the Egyptian MOHP. (10)The vaccine used was a WHO pre-qualified combined measles and rubella vaccine, that was also approved from the National Regulatory Authority (NRA) in Egypt. (11)he aim of present study was to evaluate the coverage of the MR national vaccination campaign, as one of the crucial steps to strengthen performance in the upcoming campaigns.The specific objectives are; to estimate the vaccination coverage among the targeted group (9 months to <10 years); to identify the reasons for non-vaccination during the campaign; to describe the most important sources of information used to inform people about the campaign; and to compare the assessed coverage with the administrative coverage of the MOHP.

Study setting and Design:
The survey was conducted during the period from February 15, 2016 till May, 15 2016 (3 months).It targeted children aged 9 months to less than 10 years in 26 governorates of Egypt. Figure 1 portrays the enrolled Egyptian governorates.Sampling technique and method of selection: A cluster survey was conducted based on the World Health Organization Vaccination Coverage Cluster Surveys: Reference Manual version 3 working draft July 2015 with some modifications.In WHO Reference Manual of 2015, selection of survey clusters was based on household data but in the present survey, it was based on the catchment area of health offices which was agreed upon in the preparatory meetings of the survey due to unavailability of household data for all Egyptian governorates.The sample size was calculated according to the WHO reference manual 2015 (13) equations; taking into consideration the following parameters: Each of the 26 governorates in the survey was considered as a separate stratum.Moreover, calculation of vaccination coverage in two age groups (9 months to less than 5 years and 5 years to less than 10 years) was done, where the number of strata in each governorate was two.The expected vaccination coverage in the campaign was 90%, the precision level 10%, the alpha 5%, the power 80% and the programmatic threshold 95% with delta 5% and upward direction, which resulted in effective sample size of 70.Inflation factor for non-response was 1.05.It was decided to take 24 clusters representing the 26 governorates.Ten children in the target age group were required and were enrolled from each cluster (five children from nine months to less than five years and five children from five to less than ten years).In each governorate 240 interviews were completed.In each governorate, the affiliated health offices were arranged according to the total population (the least administrative unit), and then the 24 clusters were selected by proportional allocation.Each selected cluster was divided into segments according to the population density, one segment was selected randomly to start from.The start point was also selected randomly by the principal investigator and the investigation team according to the available landmarks on the maps in the selected segment.

Statistical analysis
Data verification started in the field, with checking for completeness of the data and performing quality control checks.Data were analyzed using Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA).Version 22.0 for statistical analysis.Data were summarized and presented using appropriate descriptive statistics.

Ethical considerations
Verbal consents were obtained from interviewees (Caregivers of young children) and from school aged children themselves, prior to enrollment, after a full explanation of the aim and purpose of the evaluation survey and that their participation is voluntary.Anonymity and confidentiality of the data was ensured throughout the survey.

RESULTS
In the present study, 240 children were enrolled from each governorate.The participation rate was 99.6% (6240 children were included out of 6268 eligible children).Regarding the vaccination coverage, 98.2 % (95% C.I.= 97.87% -98.53%) of the 6240 children enrolled in the survey were vaccinated during the MR campaign).The socio-demographic characteristics of the surveyed children were shown in Regarding the distribution of vaccination coverage by sex, male children ranged from 91.8% to 100% with an overall coverage of 98.2% (95% CI = 97.7 -98.7).Considering vaccination coverage among female children, it ranged between 92.9 % and 98.2% with an overall coverage of 98.2% (95% CI = 97.7 -98.7).A coverage rate of 100% was recorded in Beni Suef, Fayoum and Souhag.The lowest coverage rates were observed in Port Said (93.3%) and Qena (93.8%).
Luxor was a special case regarding the high percentage of children vaccinated in other places as the village Diwan (20.7%).Moreover, mosques, youth clubs and village Diwan showed good contribution in vaccinating children at Aswan (13.4%),Behera (11.4%), and Fayoum (10.8%).
Table 5 portrays the different reasons for nonvaccination as mentioned by parents of non-vaccinated children (n=113).The most frequently mentioned cause was ignorance of parents about the vaccination campaign (43 children, 38.1%) which was evident in Qena, Port Said, Sharkia and Ismailia.
Ill children during the campaign contributed to 14.2% of the reasons for non-vaccination despite the long duration of the campaign.Rumors about the vaccine represented 12.4% of the causes.Such rumors were reported in Cairo, Assuit, Aswan, and Suez.In Cairo, several families mentioned their concerns about those rumors, yet at the end they vaccinated their children.
Other causes as fear of the child from injections, absence from school, having the compulsory vaccination concomitant to time of the campaign, being a busy mother, underestimating the importance of the vaccine, or inaccessibility to vaccination setting constituted 31.0% of the causes.Fear of adverse effects constituted5.3% of the causes mainly in Damietta, Ismailia , Port Said, and Sharkia .Only three children were not vaccinated due to incorrect age as calculated incorrectly by their parents.In the national campaign out of 23 million children targeted, 12093387 children between 5 and 10 years, and 11225058 children from 9 months to less than 5 years were vaccinated.Out of those, the non-Egyptian vaccinated children were 16772 and 8305 children in the two former age groups respectively.53,294 vaccination sites were included.The administrative coverage was higher in all governorates, as portrayed in the table and reached even more than 100 % in the vast majority of the governorates.

DISCUSSION
Surveys that are commonly used to estimate vaccination coverage in developing countries include demographic and health surveys, multiple indicator cluster surveys, Expanded Programme on Immunization (EPI) cluster surveys and surveys based on lot quality assurance sampling. (14,15)The EPI cluster surveys have been used to assess coverage in supplementary measles or measles-rubella immunization activities.These surveys often include some evaluation of routine immunization, the communication strategies that have been used and the reasons for non-vaccination. (16)gypt is moving in the direction to achieve the elimination of measles and rubella through high coverage (95% or more) with two doses of MRcontaining vaccine to be maintained together with periodic follow-up vaccination campaigns.It requires a political will, stewardship by national authorities and the collaboration of different concerned agencies. (17)igh quality cluster surveys are considered a routine component in monitoring the progress of immunization system within the context of the Global Vaccine Action Plan.All supplementary campaigns should include a plan or budget for an independent coverage evaluation survey as a part of general monitoring and planning. (18)In the present survey, validation of the campaign coverage determined, by the recall of administration, was done by conducting a coverage evaluation survey over 26 Egyptian governorates.
The MR vaccine campaign achieved an overall coverage of 98.2% among children aged 9 months to less than 10 years.Even with the high overall coverage rate, a proxy indicator of low immunization coverage or vaccine performance below target was observed in some districts in a couple of governorates as Port Said (93.3%) and Qena (93.8%), which might lead to "islands of low immunity" or pockets in the midst of high national vaccination coverage which pose high risk for MR transmission.
The primary cause of non-vaccination, in the present survey, was lack of awareness of the campaign.Most of the mothers reported interpersonal communication to know about the campaign including school staff.
A WHO review of the results of 13 coverage surveys conducted in 2012-2013, following 16 programmes of supplementary measles immunization was conducted in Africa.In 69% of the surveys reported, the supplementary immunization-coverage estimate based on the survey results was lower than that based on the corresponding, routinely collected administrative data.It showed that coverage surveys have become a regular component of supplementary measles immunization activities in the countries studied.Most of the reviewed surveys included some investigation of routine immunization services. (18)n the current survey the administrative vaccination coverage provided by the MOH (12) was higher in all governorates than the reported coverage.This minor discrepancy could be explained by the fact that during the campaign, all school children in fifth primary were included despite many of them were above 10 years of age, even children 11 years of age were included., meanwhile, in the present survey only children below 10 years were included.Moreover, non-Egyptian children as Syrian and others present during the campaign were vaccinated as well.
The findings of the current survey were similar to the vaccination coverage survey in Moba, Katanga, Democratic Republic of Congo (DRC), 2013.The Democratic Republic of Congo has committed to eliminate measles by 2020.In 2013, after a large outbreak, Médecins Sans Frontières conducted a mass vaccination campaign (MVC), that revealed that the measles vaccination campaign in Moba in 2013 did not achieve the 95% coverage which was the target for vaccination campaigns to eliminate measles.Their coverage estimates contrast with the estimated administrative coverage of the campaign (77%).This contrast highlights the importance of field-based coverage surveys for reliable estimates. (19)his survey in Congo identified three main barriers to vaccination during the MVC: accessibility of the villages for vaccination teams, lack of EPI measles dose at nine months and the absence of families at the time of vaccination.Six percent of children were never vaccinated.The main reason for non-vaccination was family absence 68% (95% CI 58-78). (19)

CONCLUSION & RECOMMENDATIONS
The current survey revealed that the MR vaccine campaign achieved an overall coverage of 98.2% among children aged 9 months to less than 10 years, compared to administrative vaccination coverage of 109.8%.Some clusters showed below target coverage in a couple of governorates as Port Said (93.3%) and Qena (93.8%).The most frequently mentioned cause was ignorance of parents about the vaccination campaign (43 children, 38.1%).Ill children during the campaign contributed to 14.2% of non-vaccinated children, despite the long duration of the campaign.Non-vaccination attributed to rumors about the vaccine represented 12.4% of the causes.It is recommended therefore that the country program should be praised for its efforts in implementing the national campaign but should also consider strengthening and reinforcing of intra-campaign monitoring activities in order to take immediate corrective action during campaign days for areas that have not reached the target coverage.
Trainings for campaign monitors should emphasize the importance of identifying reasons for non-vaccination in order to appropriately respond to any concerns and strengthen future campaigns.The MOH and international partners should prioritize districts in which vaccination coverage was below the target especially Port Said and Qena.These districts need high quality targeted vaccination campaigns to close the potential immunity gaps.
A well-planned timely awareness strategy to promote the importance of immunization is required.Moreover, an emphasis on effectively disseminating campaign messages and reaching those unreached is fundamental.
Concerns of parents about adverse events of MR vaccine require training of physicians and vaccine providers to improve awareness and education of the target population.Moreover, messages about vaccine safety procedures should be developed and disseminated to alleviate vaccine safety fears.
Special strategies for overcoming challenges as lack of confidence in school health providers and school vaccines, as reported, should be developed and deployed in future campaigns.

Figure 1 :
Figure 1: A map of Egypt showing the enrolled Egyptian governorates in the evaluation survey

Table 1 .
The 240 children included from each governorate, were equally distributed over the two age groups; 9 months to less than 5 years and 5 years to less than 10 years.Males constituted 51.8% while females represented 48.2% of the sampled children.More than two thirds of the fathers and mothers of the surveyed children had finished either secondary school or technical school education (45.5%, and 43.1% respectively).Illiterate parents represented 17.9% of fathers and 21.4% of mothers.

Table 1 : Distribution of the surveyed children by socio- demographic characteristics Socio-demographic characteristics
Sheikh and the New Valley governorates.The least recorded coverage rate among this age group of children was found in Port Said (95.8%),Gharbia (97.5%) and Ismailia (97.5%).Otherwise, vaccination coverage in the remaining governorates exceeded 98%.

Table 3 : Percent distribution of vaccination coverage according to age group and governorate Governorate Age of surveyed children (n=6240) 9 months-< 5 years (n surveyed=3120) 5 -≤10 years (n surveyed =3120)
*: Confidence interval is adjusted by using asymmetric technique as upper limit is above 100%