Measles-rubella surveillance and its facilitators and barriers in Bagmati province, Nepal: a mixed methods study

Nepal committed to eliminate measles-rubella by 2023 by implementing the ‘Strategic plan for measles and rubella elimination in WHO South-East Region:2020–2024’. Following the impact of the pandemic on the national immunization program and services, Nepal has now revised its target to achieve elimination by 2026. High vaccine coverage and effective surveillance systems are indispensable to achieve measles elimination. This study aimed to assess the status of measles-rubella surveillance and understand the facilitators and barriers for the measles-rubella surveillance activities in selected municipalities of selected districts of Bagmati province of Nepal. A convergent parallel mixed method study was conducted, incorporating both quantitative and qualitative approaches. It was done in eight municipalities of the three districts which were purposively selected. Eight municipalities, including both rural and urban areas, were selected from the three districts. The health facilities included in the study were: a) All the health facilities that are part of the WHO reporting unit (RU) for Vaccine-Preventable Disease (VPD) surveillance b) purposively selected health facilities outside the WHO RU. A total of 14 Key Informant Interviews (KIIs) were conducted with district and municipal stakeholders. For in-depth interviews (IDIs), two World Health Organization-Surveillance Medical Officers (WHO-SMOs) overseeing VPD surveillance and immunization activities in these districts, along with a VPD surveillance focal person from each selected reporting and non-reporting health facility, were purposively selected. The key strategies to achieve measles elimination, that is the MR2 coverage of 95%, was not achieved in most of the municipalities. The main barriers to effective VPD surveillance among others included limited awareness of VPDs under surveillance, poor understanding of the measles elimination target, and lack of clarity on standard case definitions (SCDs) for suspected measles-rubella cases. The major facilitators for effective VPD surveillance included awareness on the importance of VPD surveillance in measles elimination, availability of standard case definition posted in all reporting health facilities, and timely case notification and investigation by RUs. This study suggests that measles-rubella surveillance in the study sites can be strengthened through capacity building of health workers in VPD surveillance, ensuring the availability of the VPD surveillance field guide, availability of the dedicated focal person, emphasizing in data analysis and utilization of surveillance data.