Liberia Tackles Measles as the Ebola Epidemic Ends

As Liberia emerges from the devastating Ebola epidemic, it has been battling another disease outbreak – measles. The Ebola outbreak led to the collapse of most health services in Liberia, including routine vaccinations. A measles campaign scheduled for 2014 was suspended, leaving thousands of children susceptible. The immunity gap has led to Liberia’s worst measles outbreak in years. More than 850 cases have been reported in the past six months.

The Liberian government moved swiftly to organize a countrywide vaccination campaign with the help of the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), UNICEF and other partners. For the organizers, it was a race against time to start the campaign before the onset of the rainy season, when roads become impassable and prevent vaccinators and vaccines from reaching outlying districts. From May 8 through May 14, vaccination teams fanned out across the country immunizing hundreds of thousands of children under 5 against measles and polio and giving them deworming medicine. The campaign quickly and significantly helped slow the outbreak, but new cases are still emerging.

Measles is a highly infectious viral disease and one of the leading causes of death among young children globally. Polio is also a highly contagious viral disease that can lead to paralysis and sometimes death. Children under the age of 5 are the most vulnerable. Both diseases are easily preventable with effective and inexpensive vaccines.

Here is how Liberia tackled its first vaccination campaign in the aftermath of Ebola.

Measles vaccination team in Kolahun, Liberia (after the Ebola outbreak). Photo courtesy of WHO/M. Winkler

Liberia’s week-long integrated measles campaign began on 8 May 2015, a day before the country declared the Ebola outbreak over. In northwestern Lofa County, local health officials joined vaccination teams and organizers in the town of Kolahun to start an immunization campaign and encourage parents to vaccinate their children.

For days, social mobilizers had been spreading news of the campaign throughout Lofa. Most parents they encounter are eager to have their children protected against measles and other diseases. Hard-hit by Ebola, this county borders Guinea and Sierra Leone where transmission continues. Fear of a reintroduction of the virus runs high and many parents still worry about bringing their children anywhere near health workers or health centres that cared for Ebola patients. Such concerns are pervasive throughout the country.

Training on vaccination, Liberia (after the Ebola outbreak). Photo courtesy of WHO/M. Winkler

Organizing a vaccination campaign on the heels of the worst Ebola outbreak in history poses many challenges for the Liberian government and its partners. Extra measures to reduce risk of infection are put in place and extensive training is carried out for vaccinators, campaign supervisors and monitors.

A child being vaccinated against measles, Liberia (after the Ebola outbreak). Photo courtesy of WHO/M. Winkler

To protect from infection, handwashing stations are placed at the entrance of every vaccination post and temperature checks are required of all children and their caregivers. All supplies that touch a child during vaccination are used only once in this campaign. Vaccinators are required to change protective gloves for each and every child and to use disposable syringes and droppers. Children also drink deworming medicine from disposable plastic cups.

Nurse’s assistant records each child’s name, gender and age on the vaccination card, Monrovia, Liberia. Photo courtesy of WHO/M. Winkler

At the AfroMed Clinic in the Paynesville area of Monrovia, there is a morning rush. A vaccination site has been set up in back of the clinic. Mothers and their children wait in the shade after washing their hands and having their temperature checked. One by one, Elizabeth, a nurse’s assistant, records each child’s name, gender and age. She later checks off the vaccines and medicines administered on a yellow card that must be kept for proof of vaccination.

At the clinic, mother comforts tearful 2-year old son who has just been vaccinated for the first time, Liberia. Photo courtesy of WHO/M. Winkler

At the clinic, Musu comforts tearful 2-year old Josh who has just been vaccinated for the first time and didn’t like the taste of the deworming medication. She had hoped to get Josh vaccinated last year, but the clinics in her neighbourhood were shut down because of Ebola. “It is time to move on now,” she says. “Ebola is gone from the health centres and it’s very important for our children to be healthy and vaccinated. I don’t want my son to get measles.”

Nurse examines a child, who has white spots in his mouth, early sign of measles, Liberia. Photo courtesy of WHO/M. Winkler

It is now day 4 of the campaign and 3 children are brought in to the AfroMed Clinic with symptoms of measles, including 9-month old Aaron. Nurse Betsy Sokkalay examines his mouth and finds white spots, an early sign of measles. She separates Aaron from other children and continues to examine him, pointing out his red eyes and a rash that covers his little body. Calamine lotion helps with discomfort from the rash and Vitamin A drops are given to boost his immune response.

WHO visits clinic in Lofa Country, Liberia. Photo courtesy of WHO/M. Winkler

Adherence to protocols in this and all vaccination campaigns is critical. Supervisors and monitors, trained by WHO and other partners, ensure that all procedures are performed properly, including infection prevention and control measures and the safe collection and disposal of used needles and syringes. Here, Dr Charles Ntege of WHO visits a clinic in Lofa County’s Voinjama District. He checks to ensure the cold chain system is maintained and that vaccines are stored properly and kept cold so that they do not lose their potency.

WHO and partners meet to discuss measles vaccination coverage, Liberia. Photo courtesy of WHO/M. Winkler

Back in Montserrado, John Kromah from the County Health Team, Idong Issiet-Gibson from the US CDC, and Rosemary Onyibe of WHO meet to review coverage rates and to discuss vaccine refusals. Several communities – believing rumours that the campaign is a ruse to test an Ebola vaccine – have refused to bring in their children. The coordinators decide to meet with community leaders to try to dispel such rumours and help change minds.

Vaccinators set up a post under a tree to vaccinate children in a village, Liberia. Photo courtesy of WHO/M. Winkler

In Kpellah Town, the community leader there agrees to rally his residents to get their children vaccinated. The coordinators dispatch a mobile vaccination team to the hamlet to attract as many children as possible. Mobilizers go house to house to alert the community to the vaccination team’s arrival. The vaccinators set up a post under a large tree and the villagers bring their children to be vaccinated.

Social mobilization team spot checks vaccination cards, Liberia/ Photo courtesy of WHO/M. Winkler

It’s May 14, the final day of the vaccination campaign. It will take some time before data is collected from every vaccination team, tallied and analysed. In the city of Voinjama, there is a last-minute push to get children to vaccination sites. The district’s social mobilization lead, Abraham Focko, spot checks parents and requests to see yellow cards and the children’s fingers. He’s looking for the purple ink that is used to indicate a child has been immunized. After a number of random checks, he is pleased with the results.

Source: World Health Organization