Viva tourism sector vaccination

Pilot introduction of Vi Polysaccharide Typhoid Vaccine

through School-Based and

Tourism Sector Vaccination Programs

in the Kathmandu Valley, Nepal

Summary Report onTourism Sector Vaccination

Ministry of Health and Population, Government of Nepal

MITRA Samaj

International Vaccine Institute

1Rationale for the Typhoid Vaccination Program Typhoid fever is a disease caused by the bacterium Salmonella enterica serotype Typhi (S. Typhi) and is spread by the fecal-oral route through contaminated food or water. It continues to be a serious public health problem in many developing countries. The disease, which disproportionately affects children, is characterized by persistent fever, abdominal pain, and malaise, and often causes prolonged illness of one month or more. In about 10-15% of cases, it leads to serious complications, including hypotensive shock, perforation of the gut, and gastrointestinal hemorrhage.

In addition to the continued high incidence of typhoid fever in many areas, rapidly rising rates of antibiotic resistant strains of S. Typhi have further worsened the impact of this disease, increasing the difficulty and cost of treatment and threatening to increase case fatality from the currently estimated 1-4% to pre-antibiotic era rates of 10-20%.

Prevention measures should include improvements in water and sanitation systems, but given the huge investment these improvements require, they are far-off goals. Thus, a vaccine against typhoid is a crucial interim preventive measure. The World Health Organization (WHO) in 2000 and 2007 recommended immunization of high-risk groups. In the region, WHO South East Asia Regional Office (SEARO) recommended the prior i t izat ion of typhoid vaccines for “ immediate” implementation at a 2009 WHO SEARO meeting. Further, the National Committee on Immunization Practices (NCIP) of Nepal recommended in 2010 to consider the use of typhoid vaccines to control the disease.

• Background Typhoid, considered a “disease of the neighborhoods,” has been

in existence since antiquity, with references found in ancient Chinese texts dating back to 100 AD. Although this disease has been controlled in much of the industrialized world, it continues to affect people of many developing countries including Nepal, where it is endemic. Nepal is prone to outbreaks, with cases of typhoid fever recorded every year. In 2010, there were large outbreaks in May (173 cases) and June (650 cases) registered in the Western Regional Health Directorate of Pokhara, and in 2011, outbreaks were recorded in various locales in the Kathmandu Valley, which has been infamously named “the enteric fever capital of the world” due to many cases occurring in the general population as well as among tourists.

• Pilot Typhoid Vaccination Program The goal of the Typhoid Vaccination Program in Nepal was to

accelerate the introduction of the typhoid Vi polysaccharide vaccine in high-risk areas of the country. To meet this goal, a pilot typhoid vaccination program was carried out in two sectors – schools and the tourism industry.

The school-based vaccination program addressed the critical need of students to be protected from typhoid fever given that children and youth have the highest rates of typhoid and face a huge burden of the disease. The vaccination program for workers in the tourism industry was conducted to prevent typhoid fever in the tourism industry and among tourists, as well as to provide a funding source for the school-based program. By charging tourism sector employees or employers a nominal fee, money was collected and deposited in a revolving fund to subsidize the no-cost vaccination program for the students.

This program is a good example of a public-private partnership wherein the government took the lead in implementing the vaccination program in collaboration with a local non-governmental organization (MITRA Samaj); an international organization (International Vaccine Institute, or IVI), which provided technical assistance and funding; and a for-profit vaccine manufacturer (Sanofi Pasteur), which donated 148,600 doses of the Vi polysaccharide vaccine.

Figure 1 shows the system of vaccine procurement and the distribution of the vaccine to the tourism sector.

Figure 1 Model of the Vi Typhoid Vaccination Program

Vaccine producer

Purchase

User fee

Vaccines

Vaccination Vaccination

VaccinesNGO

District Govt.

SchoolsTourism Sector

Inauguration of the tourism vaccination program in Kathmandu, Nepal.

2• Vaccination The vaccination of tourism workers occurred from May 17, 2011

to August 11, 2011. Prior to beginning the campaign, approvals, endorsements, community mobilization, information dissemination, training, and materials procurement were required.

1. Advocacy and Project Endorsement Thirty-nine meetings were held with government officials, tourism

agencies, councils, unions, private restaurants, hotels, and tourism enterprises between November 2010 and April 2011 to seek their support and assistance in implementing the program.

• Health officials of the Ministry of Health and Population, Health Services Division, Child Health Division, and District Public Health Offices gave their approval and support for the program;

• Meetings with the Ministry of Tourism and the Nepal Tourism Board established their endorsement of the program and its inclusion as a feature of ”Nepal Tourism Year 2011”;

These efforts provided policy approval and support for importing the vaccine and implementing the vaccination, as well as approval of IEC (information, education, and communication) material and evaluative research. In addition, they generated a commitment among crucial players to facilitate and participate in the delivery of the vaccine.

2. Social Mobilization Social mobilization aimed to raise awareness of the risks,

symptoms, and methods of prevention of typhoid fever, including the benefits of the use of a vaccine against it. Members of the tourism industry were provided with multiple forms of information (e.g. posters, flyers, banners, awareness meetings, and electronic media) on typhoid fever and the upcoming typhoid vaccination. In order to provide relevant information to guide the development of IEC material and messages, formative research was conducted to assess the attitudes, knowledge, information needs, and readiness of tourism workers to use a vaccine against typhoid fever. It was also necessary to ascertain their common and credible sources of information for planning communication activities.

a. Formative Research Formative research involved qualitative data collection

through three focus groups with tourism, hotel, and restaurant employees, and six in-depth individual interviews with managers of these enterprises. This activity took place from December 16, 2010 to January 20, 2011. The findings of these studies indicated a need for:

• Information on the symptoms, causes, and methods of prevention of typhoid fever;

• Clarification that the vaccine has been licensed and used throughout the world, and is safe, effective, and protective for three years;

• Interpersonal communication through influential persons, such as doctors, community health workers, and political and administrative representatives.

These and other findings guided the development of messages, materials, and activities aimed to raise awareness of workers in the tourism industry about typhoid fever and its prevention.

b. IEC Material Distribution and Social Mobilization Social mobilization was conducted in nine geographic clusters

Rationale for the Tourism Industry VaccinationTourism is the largest employer and second largest source of foreign currency in Nepal, with 700,000 visitors in 2011. Although tourists are recommended to be vaccinated against typhoid fever when visiting Nepal, a number of them become affected with the disease every year during their visit. Top concerns among tourists who visit Nepal are sanitation, hygiene, and food safety. Use of a vaccine to prevent typhoid is an effective short-term measure to protect food handlers, tourism staff, and tourists. With 2011 declared as “Nepal Tourism Year,” there was much support in the tourism industry for a typhoid fever prevention program.

Interactive orientation meeting for tourism sector workers at a resort hotel.

A mobile booth featuring posters and interpersonal communication to foster greater awareness and understanding about typhoid.

3in urban centers and surrounding rural areas of Kathmandu, Patan, and Bhaktapur between March and June 2011. It included three phased visits by project staff that involved: 1) enumeration of establishments, 2) provision of information on typhoid and the vaccination through informational meetings with managers and delivery of IEC material, and 3) intensive dissemination of information and dialogue with members of the tourism community through the distribution of additional IEC material, use of multiple mass media channels of communication, and interpersonal meetings.

3. Vaccination Campaign The official inauguration of the project occurred on April 26, 2011

at the Nepal Tourism Board auditorium. Ministry of Health and Population officials attended, and the Director General of Health Services formally launched the program. Also present were WHO, Korea International Cooperation Agency (KOICA), UNICEF, and IVI representatives.

a. Logistics The vaccination schedule was prepared by the MITRA Samaj

social mobilization team in consultation with the vaccination team. The logistics staff organized and recorded the distribution of vaccines and the cold chain, vaccine supplies, and equipment utilized.

There were three vaccination teams made up of a physician medical supervisor, two vaccinators, and a fund collector. The teams undertook two approaches to delivering the vaccine: 1) vaccination for the staff of an individual establishment, or 2) vaccinations at a centralized location for the staff of different establishments. In both venues, the social mobilization teams provided interpersonal communication, brochures, posters, and a banner either within an establishment or delivered them door-to-door to local enterprises, associations, and in tourism congregation sites in the vicinity of a vaccination center.

There were two days of training for the social mobilization team on principles and techniques of effective communication. The vaccinators received training on safe injection practices, Good Clinical Practice (GCP), waste disposal, and cold chain maintenance.

Vaccines, supplies, and all necessary logistics, including cold chain, were managed by MITRA Samaj, which had also set up a logistics center to support these activities. Vaccines were supplied in 20-dose vials. Following the government recommendation, auto-disabled syringes were used, and waste management was monitored.

b. Fund Management After receiving informed consent, a nominal fee of 200 Nepalese

Rupees (NPR) was collected from tourism workers for the typhoid vaccination. Fees were collected from individuals by a designated fund collector and were overseen by the MITRA Samaj Finance Manager, as well as by the review of a multi-agency Fund Management Committee.

c. AEFI Management and Results Each person receiving the vaccine was requested to wait

for 15-30 minutes for observation following their vaccination. They were also provided contact numbers of medical doctors whom they could call and report any subsequent problems.

Vaccination at a tourism enterprise in Nepal.

Focus group discussion at a restaurant in Kathmandu, Nepal

Table 1: Tourism Sector VaccinationTotal

Total number of vaccination events 115

Total number of individuals vaccinated 2527

Categories of individuals vaccinated

Targeted tourism employees 2032

Relatives of targeted employees 65

MITRA Samaj (TVP NGO) 74

Non-targeted individuals 356

Payment method

Full payment by company 623

Partial payment by company 513

Self-payment 1391

Vaccinee’s affiliation

Hotel 211

Restaurant 420

Trekking agencies 128

Travel and tour 49

Resort 39

Others 738

Unknown 447

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4Additionally, the program set up a call center for inquiries and reporting of any problems following vaccination.

The medical doctor of each team assessed complaints following vaccination. A surveillance system for Adverse Events Following Immunization (AEFIs) was established following WHO guidelines and the country’s national AEFI surveillance system. The vaccination team was given training on detection and management of adverse events, a referral hospital was arranged in case of serious adverse events, and an AEFI kit with emergency medical supplies was provided to each vaccination team. There was also a vehicle available in the event of a need for immediate hospitalization.

Out of 2,527 people who were vaccinated in the tourism sector, there were six AEFI cases reported and documented. This accounted for about 0.2% of individuals vaccinated. Out of those six cases, five were minor reactions like headache, pain at the injection site, discoloration at the injection site, and allergic rashes, all of which got better within a few days. Only one person had an allergic reaction to the typhoid vaccine with generalized swelling of the body and minimal fluid in the lungs and abdomen; after investigations that ruled out other diseases, his condition improved after treatment in about 15 days.

d. Vaccination Coverage There were 115 vaccination sessions during the tourism

vaccination campaign, with 2,527 individuals vaccinated with the Vi typhoid vaccine. Table 1 shows that half of these individuals were subsidized by their employers for either full or partial payment for their vaccines. The other half of tourism employees paid for the vaccine themselves. Restaurant workers represented the largest occupation vaccinated, which was important since the pathogen, S. Typhi, is a water-borne bacteria most often transmitted through contaminated food and water.

e. Evaluation of Participation in the Vaccination An evaluation of participation in the vaccination through semi-

structured interviews with 25 vaccination participants and 50 non-participants selected through a block random sample procedure indicated that the perceived need for a typhoid vaccine to protect against the disease was influential in participation in the vaccination. Yet, both participants and non-participants desired more information on the vaccine and the vaccination program. Having to pay 200 NPR for the vaccine was mentioned as a factor that affected participation. While there are many vaccines available for adults in Nepal, adult vaccination is not common and requires multiple and reinforced forms of communication as well as ease of access to support vaccine uptake.

Highlights:• Vaccination for tourism sector workers in Kathmandu Valley was shown to be safe and feasible.

• This program builds upon the concept of a public-private partnership wherein the government, a local NGO (MITRA Samaj), an international organization (IVI), and a for-profit vaccine manufacturer (Sanofi Pasteur) joined hands.

• Despite the perceived need for a typhoid vaccine, the vaccination program covered only 2,527 persons, highlighting the challenges of vaccinating adults – a non-traditional vaccination cohort.

• Having to pay the user fee for the vaccine was a factor that affected participation, hence public and/or private financial support to reduce or remove the user fee will likely increase participation.

• Continuous education covering not only vaccination but also proper food handling and basic hygiene to tourism sector workers will be needed to attract tourism.

Typhoid vaccination at a trekking agency in Kathmandu, Nepal.

ConclusionThe vaccination campaign among tourism workers demonstrated that it is feasible to deliver the vaccine to tourism workers in the locales where they work in urban and rural centers in the Kathmandu Valley. The campaign also revealed a perceived need for a typhoid vaccine among many workers, as well as support for vaccination among their employers. Additional information about typhoid fever and use of a typhoid vaccine as a measure to prevent the disease, if delivered from credible sources such as government and medical authorities along with an accessible and inexpensive vaccination program, can lead to a broad use of the vaccine among workers in various tourism industries. Typhoid fever vaccination has the potential for wide-scale prevention of typhoid fever among workers in these industries and the tourists they serve.

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The Vi-based Vaccines for Asia (VIVA) Initiative is part of the Typhoid Program of the International Vaccine Institute. The VIVA Initiative aims to reduce mortality and morbidity due to typhoid fever in developing countries through acceleration of the adoption of Vi polysaccharide vaccines, and the development, testing, and licensure of affordable next-generation Vi-conjugate vaccines. For more information, please visit: http://viva.ivi.int.

About the Vi-based Vaccines for Asia (VIVA) Initiative:

Social mobilization teams in action in Kathmandu, Nepal.

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