Assessment of the drivers to a persistent measles outbreak among under five - year old children in Wakiso district Central Uganda.
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Introduction and Background Regardless of the availability of a safe and efficacious vaccine for the last three decades which has been protective to many lives, measles has continuously been the major cause of morbidity and mortality in most of the developing countries, including Uganda. The measles outbreaks pose a serious challenge to elimination efforts and are an indication of where national health systems and routine immunization programs need to be strengthened. Uganda registered measles outbreaks since 2016, and Wakiso district had persistent measles outbreaks between 2016 and 2018. The factors related to the persistent measles outbreak in Wakiso district and other districts have not been fully investigated. Objective: To assess the drivers to a persistent measles outbreak in Wakiso district since 2016 so as to inform prevention and response efforts against future measles outbreaks in Wakiso district and other similar settings in Uganda. Methods: A cross-sectional study, which employed both quantitative and qualitative data collection. Secondary data were extracted from multiple data sources, which included HMIS reports, DHIS-2 data, vaccine delivery notes, vaccine and injection materials control book to determine vaccines and other logistics availability. Health workers with an expert opinion on immunization were purposively selected and interviewed on service delivery and data use factors that could have contributed to the persistent outbreak in Wakiso district using a key informant guide. Results: Over-all, the number of suspected cases increased by year, 2016 (n=546) in 2017, (n=800) , and 2018 (n=3930) . The proportion of males among the suspected measles cases was higher than females 2016 (53%) and 2018 (52%), but not in 2017 (47%). In addition, the highest number of suspected measles cases was seen in the under-five (1–59 months). Only 6/22 (27%) sub-counties reported good measles vaccination coverage of 95% and above, a coverage level expected to provide herd immunity. However, suspected measles cases also kept increasing in all those sub-counties whose vaccination coverage percentage surpassed the herd immunity level. Provision of measles services was affected by several factors which included non adherence to the MoH UNEPI policy guidelines when delivering vaccination services in health facilities, lack of reliable power sources for the fridges as well as absenteeism which led to inadequately trained staff manning the vaccination sessions. In addition, some communities were resistant and did not prioritize vaccination services, despite vaccines availability throughout the three-year study period, financial limitations, transport challenges, poor attitude towards vaccination among others. These factors are likely to have contributed to poor vaccination coverage with only 27% of the sub-counties having a coverage of over 95%. The results also revealed that the district and health facilities were not conducting defaulter tracking of immunization dropout children using the child register or any other means. Furthermore, they were not monitoring their immunization performance, in addition to not using data to make informed decisions. Conclusion: The measles outbreak was persistent despite the availability of the measles vaccine and immunization services. It could be attributed to several factors which included low vaccine coverage in some subcounties, human resource challenges, financial limitations, transport challenges, poor attitude towards immunization and vaccine potency, lack of knowlegde on the catchment popualation by health workers, inability to track defaulters, inability to monitor immunization performance among others. However some of the suspected measles cases could have been rubella cases since labaratory confirmation was not undertaken for all the cases.