Maintain routine vaccination (measles, polio, pertussis, diphtheria, and tetanus) with the basic vaccination schedule. A reduction in coverage could result in a resurgence of vaccine-preventable diseases that have already been controlled and/or eradicated especially when a disaster strikes. Re-stock vaccines utilized routinely by the national immunization programs as well as biologicals, syringes and supplies. Ensure adequate stocks of Tetanus toxoid, Measles, Meningococcal, and Rabies vaccine, as their demand may be more after a disaster strikes. Ensure that Cold Chain is being maintained and an alternate plan is in place in case of its disruption. Keep adequate number of vaccine carriers/ iceboxes and thermos for use in emergency.

Mass immunization during natural disasters is counterproductive and diverts limited human resources and materials from other more effective and urgent measures.

As can be imagined, vaccination and immunization at this time have no priority and all efforts have to be directed towards issues related to survival, shelter, food, water and sanitation.

Disasters do not give rise to epidemics; in fact it is the twin combination of overcrowding, and poor water and sanitation that contribute to the increase in incidence of disease. Immunization campaigns at this time, provide a false sense of security, leading to the neglect of basic measures of hygiene and sanitation, which are more important during the emergency. It is the pressure imposed by the public, the politicians and the media that direct the demand for the launching of mass vaccinations. This is an attitude that has no valid basis in fact or experience. Indeed, experience seems to show that diverting precious energies to performing unnecessary vaccinations (for instance, against cholera or typhoid), acts to the detriment of important programs (eg malaria control).

During the recovery phase, it is essential, to continue and strengthen the vaccinations routinely practiced in the country. Epidemiological monitoring and objective information should reassure the people and their political leaders.

Mass vaccination would be justified only when the recommended sanitary measures do not have an effect and if there is evidence of the progressive increase in the number of cases with the risk of an epidemic.

Use Of Specific Vaccines Or Biologicals:

• Measles: There is a chance of measles outbreak usually if the coverage of the population prior to disaster has been sub optimal. Whenever there is a threat of measles outbreak there is need to:
  • Reduce the number of deaths by ensuring good case management and administration of Vitamin A supplementation.
  • Administer measles vaccine to all children 6 months and above (at least up to 5 years of age)
  • Include MMR vaccine in the routine immunization program as the 2nd dose of measles vaccine.
• Meningococcal vaccine: These vaccines have been used to control meningococcal meningitis due to Groups A and C in epidemic emergencies.
  • Once the increase in incidence has been determined, and the serogroup (A and/or C), age group, and affected area or region has been identified, then vaccination can be considered
  • Vaccination during non-epidemic periods is not considered to be an effective measure because of the short duration of immunity in the infant population.
• Rabies: As with human populations, animal populations are often displaced as a result of natural disasters, carrying with them zoonoses that can be transmitted to humans as well as to other animals. The availability of tissue culture rabies vaccine should be ensured.
• Tetanus: Significant increases in tetanus have not occurred after natural disasters. The mass vaccination of populations against tetanus is usually unnecessary. The best protection against tetanus is maintenance of a high level of immunity in the general population pre-disaster

• Cholera vaccine: The killed whole-cell vaccine against cholera presents low efficacy and high reactogenicity, and as a result, is not recommended for epidemic control. However, there are 3 safe, immunogenic and effective oral cholera vaccines that now exist. There is not enough information about the use of these vaccines in disaster situations and besides this, these are not routinely available in India.

In light of the availability of oral cholera vaccines, WHO convened a meeting in May 1999 on the potential use of cholera vaccines in emergency situations; and Conclusion 6 of the meeting report (WHO/CDS/EDC/99.4) states the following:

"Cholera vaccine should be considered for pre-emptive use in high risk populations before a cholera outbreak has occurred, not reactively as a method of containing an outbreak once it has started"

The following immune globulins and anti-sera should be kept handy:

Human Tetanus immunoglobulins (250 IU) IM for grossly contaminated /old wounds or Tetanus anti-sera 1500 (prophylaxis) /10,00 IU ( Therapeutic)
Anti snake venom:

• Polyvalent Anti snake venom Serum-Lyophilized - to be reconstituted with sterile water
• Each 1 ml serum neutralizes 0.6 mg of Cobra, 0.45 mg of Krait and 0.6 mg of Russell's viper's
• 0.45 of saw Scaled Viper Standard venom.

1. Evaluate damage to the cold chain and the loss of biologicals, syringes and supplies.
2. Implement the temporary use of cold boxes (RCW42) to ensure the conservation of vaccines in the affected areas and their distribution, provided that there is ice available.
3. Implement the use of photovoltaic refrigerators for vaccine storage and ice production, guaranteeing sufficient batteries.
   • Most vaccines-particularly measles vaccine-require refrigeration and careful handling if they are to remain effective.
   • If cold-chain facilities are inadequate, they should be requested for at the same time as the vaccines.
   • Vaccine donors should ensure that adequate refrigeration facilities exist in the region before dispatching vaccines.
   • The vaccination policy to be adopted should be decided at the national/state level only. Individual voluntary agencies should not decide to vaccinate on their own.

In this phase the need is to bring all services back to its former levels, at the very least. All actions should be directed to:

1. Restore the best immunization practices as per IAP guidelines.
   
2. Achieve optimum coverage with the use of UIP vaccines.
   
3. Set in place an effective disease surveillance program.