As per my experience, most of the beneficiaries are supposed to be immunized against measles. The rationale for this is that, the child will be protected against measles due to complications associated with it. The measles virus infects multiple organ systems such as the skin , the eyes, the brain, respiratory, Digestive system as well as the immune system. . When the child immune system is weak then the child can easily be malnourished or disabled or die and cannot be protected against measles if infected. Hence it is very important to provide measles vaccination in nutrition programs. Other vaccination too against other preventable diseases are important but you cannot associate it with OTP program On the vaccination categorization I agree with you too and based on my knowledge, Categorization gives an idea of, how many children within certain age group have received certain type of vaccines according to WHO Standard Immunization Schedule. This is important for monitoring and evaluating purposes whether children within certain age group receive the vaccination at the right time or not. If not, what are out factors or barriers associated with the delays as per the stipulated standard. This will also help health care providers in informed decision whether to do an assessment or not based on the data that they have.

From my knowledge and experience: Vaccinations is a must first at the emergency settings for example migration population-IDPS and refugees. Measles vaccination is the first on the priority list. It needs to be provided to al children from 6 months old to 6 15 yrs of age. Those vaccinated before 9 months must be repeated at the age of 9 months of age. The reason for this is to improve the individual and herd immunity amongst the population to reduce susceptibility for infection, or severity of the disease and also reduce outbreak. Due to financial or logistic challenges, the target is lowered to up to 5 yrs. But at times it can go to as low as targeting only those in feeding centres. In this case, during screening for different admission criteria, all of the targeted age groups children under five or so, vaccination should be provided regardless of the previous measles vaccination. We call this a campaign and a small card is provided than filling the main Child health card to difference this from routine vaccinations. In all CMAM level, vaccination must be continued. In OTP Vaccination on Measles should be continued where screening for those who did not receive the campaign vaccination against measles must continue and be vaccinated. Reason as the same to above due to lowered immunity and overcrowding in emergency setups like IDPs, screening areas as in OTP clinic, refugee settings and improper home environment. To avoid missed opportunities, ensure these children at all CMAM levels are continued to be monitored and followed for vaccination with other vaccines. This is either done by the same staffs in the OTP or the EPI teams come to vaccinate the kids on schedule. But care need to taken to avoid missed return dates as this will delay the completion of the schedule on time and exposing them to diseases being prevented. For example, anti-TB (BCG) vaccine need to ensure the child gets before or just at one year old. That is why integrated approach in interventions is always very important. We use the same event for many other interventions to reduce missed opportunities. When a mother is provided with nutrition food and informed to ensure to attend the EPI services elsewhere or another time, this is at most times time consuming and due to many chores at home and distance to the service delivery, the mother might fail to comply to this. But with food, I have experience women moving committedly to the feeding centres and back home. This is the time when postpartum FP can also be integrated and others as the causes of malnutrition is a linkage and chain of factors. I am of the opinion that in the event that the EPI team vaccinate and maintain the registers, the nutrition team need also to have a variable showing if the child was immunized on what and remaining what to ensure vaccination and avoid miss of dates or lack of referrals. I feel it is not the issue of anthropometric measurement and providing food nutrients but opportunity for other issues to be addressed. Let this child be screened and care for at 360 degrees to avoid relapse and death from other preventable or treatable causes. Thanks

due to immune deficiency most malnourished children at risk to affect by measles nutrition program consider measles but cover Vaccination types also for this reason all OTP programs together with therapeutic food support monitoring child vaccination measles doses EPI program is separate or integrated in some areas Nutrition staff just will referral this child to near EPI center and all EPI programs has common monitoring tools like registration books and vaccination card which hold by care giver and showed current child vaccination situation and schedule for next doses by this we will avoid missing or double counting

I do agree with all the opinions above. Thanks. Just to add: It is recommended that in every programme there is need for outreach services and static iste vaccination. Unfortunately due shortage in human resources, static at the MCH clinic in a health facility is specified either once or twice a week. The reason to this is that the same few (may be only two) staffs are the ones moving out to outreach sites during the remaining days of the week. In this context, I would prefer the nurse/s in the feeding programme to take the vaccines and vaccinate the child if due but the EPI team not available, than letting the child to come next time when EPI is available. If a staff has a mixed tasks, better to utilize than letting the child miss this opportunity until next time. This has at times happened and I am of a strong opinion that it must not happen. I mean being aware of when every child return date for each services is very crucial and integrated services than dealing on one part is never benefit the beneficiaries at all. Otherwise we will be sending children home when they come for food nutrients but mission other services. This at times happens through my experience. My observation is hat one nurse in health facility and o outreach is just too much knowing that not all outreach sites are nutrition outreach sites. nutrition area coverage can be much less than the EPI coverage in any area. Nutrition teams target specific target areas for outreaches ut EPI targets all the population. Not all EPI eligible children come for nutrition making the EPIstaffs cover more areas. Thanks again, Cornelia

measles injection is given on the 4th visit for severely malnourished children because of the reductive adaptation process that makes the body not to make antibodies once the injection is given to the child. The antibodies starts to form by the 4h week thats when the immune system is able to mount an attack. Below 4weeks these systems(endocrine, immune) are not able to function so giving Measles vaccines will not trigger any antibody formation that will mount protection against measles

Remember measles vaccine is live attenuated 

Hi Masud,

There are numerous protocols and you should follow those in your national guidelines.

The rationale for giving a vaccine on the 4th visit was a compromise position between giving 2 doses, once on admission and once on discharge - the immune response supposedly improving during recovery from SAM, and adequately by the 4th week. This assumption of adequate recovery by week 4 obviously has a number of limitations for individuals. Not all children recover the same and some children will default from treatment before week 4. 

Emergency programmes also advocated giving children aged 6-12 months the measles vaccine in OTP to be repeated on discharge or when the child reaches 9 months (the assumed age when the immune system reaches maturity). Alternatively, guidelines for programmes integrated into primary health services will suggest 'referral to EPI' (excluding children 6-8 month old). This is probably an acceptable approach where national / local measles coverage is high.

Which is the best approach is context dependent. Where there is low vaccination coverage or where a lot of default from OTP occurs early in treatment, one might consider giving the vaccination on admission - including children 6-8 months.

Jones and Berkely (2014) write "the suggestion that delayed vaccination is more likely to result in protective titres is not supported by available evidence". The article also provides WHO guidance on age-related vaccination in children with SAM

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4266374/ 

I hope this helps,

Paul