Study: Immunize refugee children early to prevent deadly measles

November 05, 2001

COLUMBUS, Ohio -- Children of refugees should be immunized against deadly measles outbreaks within two weeks after they enter a new country, according to a report in the current issue of the American Journal of Public Health.

The report was co-authored by Darryl Koop, medical resident and former graduate student in public health at Ohio State University, who cared for refugees of the Kosovo war in 1999.

According to the World Health Organization, one million children die from measles each year. The virus infects the respiratory tract and spreads throughout the body, and is transmitted by airborne droplets breathed or coughed by a contagious person.

Measles remains one of the leading causes of childhood mortality in refugee situations, Koop said, and the children of Afghanistan could be especially at risk. "Years of internal conflict have disrupted the Afghan public health infrastructure that is responsible for immunizing children," he said. "That, coupled with the existence of childhood malnutrition in the country will put many Afghan children at risk of contracting -- or even dying from -- various diseases, including measles."

"Malnourished children are more vulnerable to the measles virus, and it will kill, especially in children age 2 or younger," he continued.

Koop expects to see vaccinations become a top priority in refugee camps. "Ideally, all children age 5 and under should receive a shot even before the tents go up," he said. "If that's not possible, then within the first few weeks."

Benita Jackson, associate dean for clinical affairs and Koop's advisor, said that medical volunteers can easily lose track of refugees once they enter a country. Displaced families tend to migrate from camp to camp, until they find a place in the host community to settle down. Plus, refugees may arrive injured and require urgent medical care.

"These camps are the emergency rooms of the world," Jackson said. "Doctors have to treat the most urgent cases first, just as they would in a hospital."

Koop explained that the Kosovar refugee population mixed freely with local populations in the host country. In that situation, diseases can spread between the two populations.

While Koop was in Macedonia, he coordinated the Expanded Program on Immunization for the International Medical Corps, a non-governmental organization that dispatches medical aid to refugee sites around the world. The trip provided Koop with required practicum experience for his master's degree in public health from Ohio State. Koop and Jackson authored the resulting report with Gilbert Nestel, a recently retired professor of public health. The report details how fluctuating camp populations in Macedonia affected the number of children who were immunized against measles and other vaccine-preventable diseases. Overall vaccination rates were as low as 70 percent in some refugee camps, and as high as 100 percent in others.

For six weeks, Koop traveled between seven camps immunizing children with vaccines provided by UNICEF, and evaluating the vaccine capabilities in Kosovo after the war ended. The weeks passed quietly, aside from one very late night when he delivered a Kosovar couple's baby in a pickup truck on the way to the hospital.

He kept detailed immunization records. Of the 261,000 refugees in Macedonia in June 1999, some 110,000 were living in the camps. The others stayed with relatives, friends, or volunteer families. Children under the age of 4 represented approximately 10 percent of the camps' population.

Rather than immunize children as soon as they entered the camps, medical volunteers had to follow the Macedonian national immunization schedule, as defined by the Macedonian Ministry of Health. That meant waiting several weeks before immunizing all children below the age of 4 against eight different childhood diseases, rather than only measles.

By not immediately immunizing the children, the Macedonian government risked a measles outbreak, the Ohio State researchers concluded. But the volunteers had no real choice in the matter.

"In a refugee situation, volunteers are basically guests in another country, and they have to play by that country's rules. The local government has to agree to the immunization schedule. Available resources can also be an issue," Koop said.

No outbreak occurred in the Macedonian camps, most likely because the Kosovar children were healthy to begin with, he said.

For the future, the researchers recommend that all refugee children age 5 or younger should receive a measles shot immediately upon entering a camp. If camp populations are not as stable as they were in Macedonia, Koop said, then establishing a permanent clinic with vaccination capabilities in each camp would ensure better protection for the children -- not just for measles, but for all vaccine-preventable illnesses.

Currently, Koop is working in several rural emergency rooms in southeastern Ohio, while he waits to take his certification board exam in general preventive medicine and public health in November. After that, he may take his specialty in international public health to Pakistan to assist with Afghan refugees -- a population that is expected to grow in that country throughout the new year.
Contact: Darryl Koop, (614) 833-6492;
Benita Jackson, (614) 293-8997;

Written by Pam Frost Gorder, (614) 292-9475;

Editor's note: photos for this story are available to the media at or at (614) 292-9475.

Ohio State University

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