Moving forward with strengthening routine immunization delivery as part of measles and rubella elimination activities

Assessing the impact of polio supplementary immunisation activities on routine immunisation and health systems: a systematic review

Introduction

The Global Polio Eradication Initiative uses polio supplementary immunisation activities (SIAs) as a strategy to increase vaccine coverage and cease poliovirus transmission. Impact of polio SIAs on immunisation systems is frequently debated. We reviewed the impact of polio SIAs on routine immunisation and health systems during the modern era of polio eradication.

Methods

We searched nine databases for studies reporting on polio SIAs and immunisation coverage, financial investment, workforce and health services delivery. We conducted a narrative synthesis of evidence. Records prior to 1994, animal, modelling or case studies data were excluded.

Results

20/1637 unique records were included. Data on vaccine coverage were included in 70% (14/20) studies, workforce in 65% (13/20) and health services delivery in 85% (17/20). SIAs positively contributed to vaccination uptake of non-polio vaccines in seven studies, neutral in three and negative in one. Some polio SIAs contributed to workforce strengthening through training and capacity building. Polio SIAs were accompanied with increased social mobilisation and community awareness building confidence in vaccination programmes. Included studies were programmatic in nature and contained variable data, thus could not be justly critically appraised.

Conclusion

Polio SIAs are successful at increasing polio vaccine coverage, but the resources and infrastructures were not always utilised for delivery of non-polio vaccines and integration into routine service delivery. We found a gap in standardised tools to evaluate SIAs, which can then inform service integration. Our study provides data to inform SIAs evaluations, and provides important considerations for COVID-19 vaccine roll-out to strengthen health systems.

PROSPERO registration number

CRD42020152195.

Advancing sustainable development goals through immunization: a literature review

BACKGROUND

Immunization directly impacts health (SDG3) and brings a contribution to 14 out of the 17 Sustainable Development Goals (SDGs), such as ending poverty, reducing hunger, and reducing inequalities. Therefore, immunization is recognized to play a central role in reaching the SDGs, especially in low- and middle-income countries (LMICs). Despite continuous interventions to strengthen immunization systems and to adequately respond to emergency immunization during epidemics, the immunization-related indicators for SDG3 lag behind in sub-Saharan Africa. Especially taking into account the current Covid19 pandemic, the current performance on the connected SDGs is both a cause and a result of this.

METHODS

We conduct a literature review through a keyword search strategy complemented with handpicking and snowballing from earlier reviews. After title and abstract screening, we conducted a qualitative analysis of key insights and categorized them according to showing the impact of immunization on SDGs, sustainability challenges, and model-based solutions to these challenges.

RESULTS

We reveal the leveraging mechanisms triggered by immunization and position them vis-à-vis the SDGs, within the framework of Public Health and Planetary Health. Several challenges for sustainable control of vaccine-preventable diseases are identified: access to immunization services, global vaccine availability to LMICs, context-dependent vaccine effectiveness, safe and affordable vaccines, local/regional vaccine production, public-private partnerships, and immunization capacity/capability building. Model-based approaches that support SDG-promoting interventions concerning immunization systems are analyzed in light of the strategic priorities of the Immunization Agenda 2030.

CONCLUSIONS

In general terms, it can be concluded that relevant future research requires (i) design for system resilience, (ii) transdisciplinary modeling, (iii) connecting interventions in immunization with SDG outcomes, (iv) designing interventions and their implementation simultaneously, (v) offering tailored solutions, and (vi) model coordination and integration of services and partnerships. The research and health community is called upon to join forces to activate existing knowledge, generate new insights and develop decision-supporting tools for Low-and Middle-Income Countries' health authorities and communities to leverage immunization in its transformational role toward successfully meeting the SDGs in 2030.

Potential for improving routine immunisation waste management using measles vaccination campaign 2017 in Kebbi State, Nigeria

BACKGROUND

Immunisation activities generate sharps and infectious non-sharp waste that have harmful impact on the community and health care workers if disposed of improperly, leading to carbon mono oxide (CO) emissions which contribute to global warming. Health care waste is not effectively managed, especially in some developing countries. However, measles supplemental immunisation activities (SIAs) are used to strengthen routine immunisation system, including waste management. The waste management planning provides an opportunity to build capacity, mobilize resources and strengthen structures to ensure continual disposal of routine immunisation waste.

METHODS

We reviewed the Kebbi State and LGA routine immunisation waste management situation and identified existing gaps; developed and implemented the plan for waste management, including strengthening routine immunisation waste management. The process included, reactivation of measles technical coordination committee, mobilizing resources for funding, and sustenance of immunisation waste management. The health care workforce was trained in safe immunisation waste disposal practices.

RESULTS

Immunisation waste management committee and the structure was established and strengthened at the state and LGA levels and a total cost of 11,710.70 USD was expended on injection waste management, with an average cost per injection of 0.01 USD. A total of 11,829 safety boxes were incinerated in the state, including those generated from routine immunisation sessions. Twenty-one Local Immunisation Officers, 1097 and 2192 team supervisors and healthcare worker vaccinators respectively were trained on immunisation waste disposal.

CONCLUSION

Immunisation waste management strategies protect healthcare workers and reduce the adverse impact on the environment. Improving key areas such as human and financial resources ensures accountability towards sustainable healthcare waste management.

Assessment of immune status against measles, mumps, and rubella in young Kuwaitis: MMR vaccine efficacy

Seroprevalence studies on measles, mumps, and rubella immunoglobulin G (IgG) antibodies after the implementation of the measles-mumps-rubella (MMR) vaccine are lacking in Kuwait. This study is an age-stratified serological study to assess the herd immunity to measles, mumps, and rubella among the young Kuwaiti population to evaluate the effectiveness of the MMR vaccine. IgG antibody titers to mumps, measles, and rubella were determined with commercial immune-assay in serum samples of 1000 Kuwaitis aged 5 to 20 years. The highest level of seropositivity was to measles (94.6%), which was significantly higher in females than in males. The highest seronegativity was for mumps (29%). The percentage of the young Kuwaiti population who were serologically positive for all the components of the MMR vaccine was 47%, and 2% of the individuals were without any protective antibodies to measles, mumps, and rubella. Females aged 5 to 10 years were best protected to rubella; however, seronegativity in 8.2% of 11- to 20-year-old females makes them vulnerable to rubella virus infection and congenital complications during pregnancy. The study provided insight into the effect of the MMR vaccine on seroprevalence of antibodies against measles, mumps, and rubella in Kuwait, which will contribute to the global knowledge base of vaccine coverage and help to inform elimination strategies. The findings strengthen the need for a third dose of MMR vaccine and catch-up campaigns for the young Kuwaiti population to increase vaccination coverage and prevent waning immunity, especially among those who received only one dose of the vaccine during childhood.

Strengthening routine immunization through measles-rubella elimination

The 2016 mid-term review of the Global Measles-Rubella Strategic Plan 2012-20 for achieving measles-rubella elimination concluded that the full potential of strategies and activities to strengthen routine immunization (RI) service delivery had not been met. In December 2017, we contacted WHO and partner agency immunization staff in all six WHO Regions who identified 23 countries working on measles or rubella elimination that have implemented examples of recommended activities to improve RI, adapted to their needs. Among those examples, opportunities to strengthen RI through implementing supplementary immunization activities (SIAs) were reported most frequently, including advocacy for immunization and educational activities targeted at the public and skills training targeted at health professionals. The expansion of cold chain capacity to accommodate supplies required for SIAs facilitated widening RI service delivery to reach more communities, introduce new vaccines, and reduce the risk of vaccine stock-outs. Substantial numbers of under-vaccinated children, according to the national immunization schedule, have been identified during SIAs, but it is not possible to confirm whether these children actually received missing RI doses. Micro-planning exercises for SIAs have generated data that permitted the revision of catchment populations for fixed site and outreach RI services. Some countries reported using the opportunity afforded by measles/rubella elimination to strengthen overall vaccine-preventable disease surveillance and outbreak preparedness and to introduce mandatory school-entry vaccination requirements covering other vaccines in addition to measles and rubella. Unfortunately, we were unable to obtain information regarding the cost, impact or sustainability of these activities. The evaluation of the many other strategies that have been deployed in recent years to strengthen RI systems and raise vaccination coverage was beyond the scope of this survey. We conclude by providing recommendations to encourage more countries to adapt and implement a comprehensive set of RI-strengthening activities in association with the MR elimination goal.

Impact of an Intervention to Use a Measles, Rubella, and Polio Mass Vaccination Campaign to Strengthen Routine Immunization Services in Nepal

Background

The potential to strengthen routine immunization (RI) services through supplementary immunization activities (SIAs) is an important benefit of global measles and rubella elimination and polio eradication strategies. However, little evidence exists on how best to use SIAs to strengthen RI. As part the 2012 Nepal measles-rubella and polio SIA, we developed an intervention package designed to improve RI processes and evaluated its effect on specific RI process measures.

Methods

The intervention package was incorporated into existing SIA activities and materials to improve healthcare providers' RI knowledge and practices throughout Nepal. In 1 region (Central Region) we surveyed the same 100 randomly selected health facilities before and after the SIA and evaluated the following RI process measures: vaccine safety, RI planning, RI service delivery, vaccine supply chain, and RI data recording practices. Data collection included observations of vaccination sessions, interviews with the primary healthcare provider who administered vaccines at each facility, and administrative record reviews. Pair-matched analytical methods were used to determine whether statistically significant changes in the selected RI process measures occurred over time.

Results

After the SIA, significant positive changes were measured in healthcare provider knowledge of adverse events following immunization (11% increase), availability of RI microplans (+17%) and maps (+12%), and awareness of how long a reconstituted measles vial can be used before it must be discarded (+14%). For the SIA, 42% of providers created an SIA high-risk villages list, and >50% incorporated this information into RI outreach session site planning. Significant negative changes occurred in correct knowledge of measles vaccination contraindications (-11%), correct definition for a measles outbreak (-21%), and how to treat a child with a severe adverse event following immunization (-10%). Twenty percent of providers reported cancelling ≥1 RI sessions during the SIA. Many RI process measures were at high proportions (>90%) before the SIA and remained high afterward, including proper vaccine administration techniques, proper vaccine waste management, and availability of vaccine carriers and vaccine registers.

Conclusions

Focusing on activities that are easily linked between SIAs and RI services, such as using SIA high-risk village list to strengthen RI microplanning and examining ways to minimize the impact of an SIA on RI session scheduling, should be prioritized when implementing SIAs.

Impact of the Ebola outbreak on routine immunization in western area, Sierra Leone - a field survey from an Ebola epidemic area

Background

Since March 2014, the Ebola Virus Disease (EVD) outbreak in West Africa disrupted health care systems - especially in Guinea, Liberia and Sierra Leone – with a consequential stress on the area’s routine immunization programs. To address perceived decreased vaccination coverage, Sierra Leone conducted a catch-up vaccination campaign during 24–27 April 2015. We conducted a vaccination coverage survey and report coverage estimates surrounding the time of the EVD outbreak and the catch-up campaign.

Methods

We selected 3 villages from each of 3 communities and obtained dates of birth and dates of vaccination with measles vaccine (MV) and the 3rd dose of Pentavalent vaccine (Pentavalent3) of all children under 4 years of age in the 9 selected villages. Vaccination data were obtained from parent-held health cards. We calculated the children’s MV and Pentavalent3 coverage rates at 3 time points, 1 August 2014, 1 April 2015, and 1 May 2015, representing coverage rates before the EVD outbreak, during the EVD outbreak, and after the Maternal and Child Health Week (MCHW) catch-up campaign.

Results

The final sample size was 168 children. MV coverage among age-eligible children was 71.3% (95% confidence interval [CI]: 62.1% - 80.4%) and 45.7% (95% CI: 29.2% - 62.2%) before and during the outbreak of EVD, respectively, and was 56.8% (95% CI: 40.8% - 72.7%) after the campaign. Pentavalent3 coverage among age-eligible children was 79.8% (95% CI: 72.6% - 87.0%) and 40.0% (95% CI: 22.5% - 57.5%) before and during the outbreak of EVD, and was 56.4% (95% CI: 39.1% - 73.4%) after the campaign.

Conclusions

Coverage levels of MV and Pentavalent3 were low before the EVD outbreak and decreased further during the outbreak. Although the MCHW catch-up campaign increased coverage levels, coverage remained below pre-outbreak levels. High-quality supplementary immunization activities should be conducted and routine immunization should be strengthened to address gaps in immunity among children in this EVD-affected area.

One year of campaigns in Cameroon: effects on routine health services

BACKGROUND

Targeted campaigns have been reported to disrupt routine health services in low- and middle-income countries. The objective of this study was to evaluate the average effect of public health campaigns over 1 year on routine services such as antenatal care, routine vaccination and outpatient services.

METHOD

We collected daily activity data in 60 health facilities in two regions of Cameroon that traditionally undergo different intensities of campaign activity, the Centre region (low) and the Far North (high), to ascertain effects on routine services. For each outcome, we restricted our analysis to the public health centres for which good data were available and excluded private health facilities given their small number. We used segment-linear regression to account for the longitudinal nature of the data, and assessed whether the number of routine activities decreased in health facilities during periods when campaigns occurred. The analysis controlled for secular trends and serial correlation.

RESULTS

We found evidence that vaccination campaigns had a negative impact on routine activities, decreasing outpatient visits when they occurred (Centre: -9.9%, P = 0.079; Far North: -11.6%, P = 0.025). The average negative effect on routine services [outpatient visits -18% (P = 0.02) and antenatal consultations -70% [P = 0.001]) was most pronounced in the Far North during 'intensive' campaigns that usually require high mobilization of staff.

DISCUSSION

With an increasing number of interventions delivered by campaigns and in the context of elimination and eradication targets, these are important results for countries and agencies to consider. Achieving disease control targets hinges on ensuring high uptake of routine services. Therefore, we suggest that campaigns should systematically monitor 'impact on routine services', while also devising concrete strategies to mitigate potential adverse effects.

Evaluation of impact of measles rubella campaign on vaccination coverage and routine immunization services in Bangladesh

Background

Like other countries in Asia, measles-rubella (MR) vaccine coverage in Bangladesh is suboptimal whereas 90–95 % coverage is needed for elimination of these diseases. The Ministry of Health and Family Welfare (MOHFW) of the Government of Bangladesh implemented MR campaign in January-February 2014 to increase MR vaccination coverage. Strategically, the MOHFW used both routine immunization centres and educational institutions for providing vaccine to the children aged 9 months to <15 years. The evaluation was carried out to assess the impact of the campaign on MR vaccination and routine immunization services.

Methods

Both quantitative and qualitative evaluations were done before and after implementation of the campaign. Quantitative data were presented with mean (standard deviation, SD) for continuous variables and with proportion for categorical variables. The overall and age- and sex-specific coverage rates were calculated for each region and then combined. Categorical variables were compared by chi-square statistics. Multiple logistic regression analysis were performed to estimate odds ratios (OR) and 95 % confidence intervals (CI) of coverage associated with covariates, with adjustment for other covariates. Qualitative data were analyzed using content analysis.

Results

The evaluations found MR coverage was very low (<13 %) before the campaign and it rose to 90 % after the campaign. The pre-post campaign difference in MR coverage in each stratum was highly significant (p < 0.001). The campaign achieved high coverage despite relatively low level (23 %) of interpersonal communication with caregivers through registration process. Child registration was associated with higher MR coverage (OR 2.91, 95 % CI 1.91–4.44). Children who attended school were more likely to be vaccinated (OR 8.97, 95 % CI 6.17–13.04) compared to those who did not attend school. Children of caregivers with primary or secondary or higher education had higher coverage compared to children of caregivers with no formal education. Most caregivers mentioned contribution of the campaign in vaccination for the children not previously vaccinated.

Conclusions

The results of the evaluation indicated that the campaign was successful in terms of improving MR coverage and routine immunization services. The evaluation provided an important guideline for future evaluation of similar efforts in Bangladesh and elsewhere.

Cluster survey evaluation of a measles vaccination campaign in Jharkhand, India, 2012

Introduction

India was the last country in the world to implement a two-dose strategy for measles-containing vaccine (MCV) in 2010. As part of measles second-dose introduction, phased measles vaccination campaigns were conducted during 2010–2013, targeting 131 million children 9 months to <10 years of age. We performed a post-campaign coverage survey to estimate measles vaccination coverage in Jharkhand state.

Methods

A multi-stage cluster survey was conducted 2 months after the phase 2 measles campaign occurred in 19 of 24 districts of Jharkhand during November 2011–March 2012. Vaccination status of children 9 months to <10 years of age was documented based on vaccination card or mother’s recall. Coverage estimates and 95% confidence intervals (95% CI) for 1,018 children were calculated using survey methods.

Results

In the Jharkhand phase 2 campaign, MCV coverage among children aged 9 months to <10 years was 61.0% (95% CI: 54.4–67.7%). Significant differences in coverage were observed between rural (65.0%; 95% CI: 56.8–73.2%) and urban areas (45.6%; 95% CI: 37.3–53.9%). Campaign awareness among mothers was low (51.5%), and the most commonly reported reason for non-vaccination was being unaware of the campaign (69.4%). At the end of the campaign, 53.7% (95% CI: 46.5–60.9%) of children 12 months to <10 years of age received ≥2 MCV doses, while a large proportion of children remained under-vaccinated (34.0%, 95% CI: 28.0–40.0%) or unvaccinated (12.3%, 95% CI: 9.3–16.2%).

Conclusions

Implementation of the national measles campaign was a significant achievement towards measles elimination in India. In Jharkhand, campaign performance was below the target coverage of ≥90% set by the Government of India, and challenges in disseminating campaign messages were identified. Efforts towards increasing two-dose MCV coverage are needed to achieve the recently adopted measles elimination goal in India and the South-East Asia region.

Profiling of measles-specific humoral immunity in individuals following two doses of MMR vaccine using proteome microarrays

INTRODUCTION

Comprehensive evaluation of measles-specific humoral immunity after vaccination is important for determining new and/or additional correlates of vaccine immunogenicity and efficacy.

METHODS

We used a novel proteome microarray technology and statistical modeling to identify factors and models associated with measles-specific functional protective immunity in 150 measles vaccine recipients representing the extremes of neutralizing antibody response after two vaccine doses.

RESULTS

Our findings demonstrate a high seroprevalence of antibodies directed to the measles virus (MV) phosphoprotein (P), nucleoprotein (N), as well as antibodies to the large polymerase (L) protein (fragment 1234 to 1900 AA). Antibodies to these proteins, in addition to anti-F antibodies (and, to a lesser extent, anti-H antibodies), were correlated with neutralizing antibody titer and/or were associated with and predictive of neutralizing antibody response.

CONCLUSION

Our results identify antibodies to specific measles virus proteins and statistical models for monitoring and assessment of measles-specific functional protective immunity in vaccinated individuals.

Updating the evidence base on the operational costs of supplementary immunization activities for current and future accelerated disease control, elimination and eradication efforts

BACKGROUND

To achieve globally or regionally defined accelerated disease control, elimination and eradication (ADC/E/E) goals against vaccine-preventable diseases requires complementing national routine immunization programs with intensive, time-limited, and targeted Supplementary Immunization Activities (SIAs). Many global and country-level SIA costing efforts have historically relied on what are now outdated benchmark figures. Mobilizing adequate resources for successful implementation of SIAs requires updated estimates of non-vaccine costs per target population.

METHODS

This assessment updates the evidence base on the SIA operational costs through a review of literature between 1992 and 2012, and an analysis of actual expenditures from 142 SIAs conducted between 2004 and 2011 and documented in country immunization plans. These are complemented with an analysis of budgets from 31 SIAs conducted between 2006 and 2011 in order to assess the proportion of total SIA costs per person associated with various cost components. All results are presented in 2010 US dollars.

RESULTS

Existing evidence indicate that average SIA operational costs were usually less than US$0.50 per person in 2010 dollars. However, the evidence is sparse, non-standardized, and largely out of date. Average operational costs per person generated from our analysis of country immunization plans are consistently higher than published estimates, approaching US$1.00 for injectable vaccines. The results illustrate that the benchmarks often used to project needs underestimate the true costs of SIAs and the analysis suggests that SIA operational costs have been increasing over time in real terms. Our assessment also illustrates that operational costs vary across several dimensions. Variations in the actual costs of SIAs likely to reflect the extents to which economies of scale associated with campaign-based delivery can be attained, the underlying strength of the immunization program, sensitivities to the relative ease of vaccine administration (i.e. orally, or by injection), and differences in disease-specific programmatic approaches. The assessment of SIA budgets by cost component illustrates that four cost drivers make up the largest proportion of costs across all vaccines: human resources, program management, social mobilization, and vehicles and transportation. These findings suggest that SIAs leverage existing health system infrastructure, reinforcing the fact that strong routine immunization programs are an important pre-requisite for achieving ADC/E/E goals.

CONCLUSIONS

The results presented here will be useful for national and global-level actors involved in planning, budgeting, resource mobilization, and financing of SIAs in order to create more realistic assessments of resource requirements for both existing ADC/E/E efforts as well as for new vaccines that may deploy a catch-up campaign-based delivery component. However, limitations of our analysis suggest a need to conduct further research into operational costs of SIAs. Understanding the changing face of delivery costs and cost structures for SIAs will continue to be critical to avoid funding gaps and in order to improve vaccination coverage, reduce health inequities, and achieve the ADC/E/E goals many of which have been endorsed by the World Health Assembly and are included in the Decade of Vaccines Global Vaccine Action Plan.