Performance and determinants of routine immunization coverage within the context of intensive polio eradication activities in Uttar Pradesh, India: Social Mobilization Network (SM Net) and Core Group Polio Project (CGPP)

Social mobilization campaign to tackle immunization hesitancy in Sargodha and Khushab districts of Pakistan

Background

Immunization hesitancy is a delay in acceptance or refusal of vaccines despite availability of vaccination services. If people are not engaged appropriately via communication and social mobilization, doubts about the trade-offs between the benefits and potential side effects persist. The objective of this study was to explore strategies for improved social mobilization to reduce immunization hesitancy.

Methods

Mix of quantitative and qualitative approaches was applied to collect data from a diverse group of respondents in Sargodha and Khushab districts. Quantitative data were collected from 329 community health workers, including vaccinators, lady health workers and lady health supervisors, and school health and nutrition supervisors. In addition, qualitative data were collected from top management of Expanded Programme on Immunization (EPI) through key informant interviews (KIIs) and focus group discussions (FGDs) were conducted with parents. Analysis has been done using SPSS software and detailed transcriptions.

Results

Advocacy meetings with local influencers, community group sessions, door-to-door visits by community health workers and mosque announcements are considered the most relevant and appropriate interventions for social mobilization. Community Health Workers (CHWs), cognizant of local culture, are being trusted, though optimum performance is achievable with adequate redressal of hesitancy concerns. However, in some cases negative attitudes of people towards immunization hinder trust towards mobilizers or CHWs. Hence, they leverage active participation of local influencers, teachers and health department officials to convince such stubborn parents. Active community involvement through leveraging support from local religious and non-religious influencers in social mobilization activities increases its acceptance. Community engagement is most effective in rural and hard-to-reach areas when community health workers are skilled in interpersonal communication and information education communication.

Conclusions

Communication committees as oversight mechanism should be established or reactivated to regularly monitor and support mobilization activities through managing affairs like speedy liaison with local administration and local influencers, mobilizers' service related concerns, community-specific hurdles, and deficiencies of awareness-material provision that eventually improves mobilization performance. Resistant community's needs can be redressed through rigorous conduct of men's and women's education sessions by CHWs while giving more time and space to mobilizers to take on board local religious and non-religious influencers to convince conservative/illiterate parents. Higher management should fix policy implementation slippages like training needs assessment of mobilizers and Civil Society Organizations' involvement framework.

Effectiveness of a community-level social mobilization intervention in achieving the outcomes of polio vaccination campaigns during the post-polio-endemic period: Evidence from CORE Group polio project in Uttar Pradesh, India

BACKGROUND

A social mobilization (SM) initiative contributed to India's success in polio elimination. This was the CORE Group Polio Project (CGPP) India, a partner of the Uttar Pradesh (UP) SM Network and which continued its SM activities, even during the polio-free period through a network of multi-level social mobilizers. This paper assesses the effects of this community-level SM (CLSM) intervention on the extent of community engagement and performance of polio Supplementary Immunization Activity campaigns (SIAs) during the post-polio-endemic period (i.e., from March 2012 to September 2017).

METHODS

This study followed a quasi-experimental design. We used secondary, cluster-level data from CGPP India's Management Information System, including 52 SIAs held from January 2008 to September 2017, covering 56 blocks from 12 districts of UP. We computed various indicators and performed Generalized Estimating Equations based analysis to assess the statistical significance of differences between the outcomes of intervention and non-intervention areas. We then estimated the effects of the SM intervention using Interrupted time-series, Difference-in-Differences and Synthetic Control Methods. Finally, we estimated the population influenced by the intervention.

RESULTS

The performance of polio SIAs changed over time, with the intervention areas having better outcomes than non-intervention areas. The absence of CLSM intervention during the post-polio-endemic period would have negatively impacted the outcomes of polio SIAs. The percentage of children vaccinated at polio SIA booths, percentage of 'X' houses (i.e., households with unvaccinated children or households with out-of-home/out-of-village children or locked households) converted to 'P' (i.e., households with all vaccinated children or households without children eligible for vaccination), and percentage of resistant houses converted to polio acceptors would have gone down by 14.1 (Range: 12.7 to 15.5), 6.3 (Range: 5.2 to 7.3) and 7.4 percentage points, respectively. Community engagement would have reduced by 7.2 (Range: 6.6 to 7.7) percentage points.

CONCLUSIONS

The absence of CLSM intervention would have significantly decreased the level of community engagement and negatively impacted the performance of polio SIAs of the post-polio-endemic period. The study provides evidence of an added value of deploying additional human resource dedicated to social mobilization to achieve desired vaccination outcomes in hard-to-reach or programmatically challenging areas.

The Potential Contribution of Supplementary Immunization Activities to Routine Immunization in Kebbi State, Nigeria

Background: Among the strategies of the Polio Eradication Initiative, the landmark interventions are routine immunization (RI) and supplementary immunization activities (SIAs). RI is the provision of vaccination service at the health facility and conducted year-round. SIAs are a community-based intervention targeting large numbers of an eligible population within a short period. Hence, the study aimed to assess the contributions of SIAs on access and utilization of RI services. Methods: We conducted the study in 10 local government areas in Kebbi State, northwestern Nigeria. We analyzed RI data from January to September 2019 and included the 4 SIAs conducted in January, April, August, and September in the same years. The number of children vaccinated, the trend of BCG, pentavalent vaccine at 6 and 10 weeks, and measles coverage and dropout rates (DORs) were analyzed. Results: For all the selected vaccines, the highest contributions to RI were recorded during the August 2019 fractional Inactivated Polio Vaccine (fIPV) campaign. On the other hand, the least contributions were noted during January SIAs. The BCG coverage showed an erratic trend with the lowest in February and highest in July 2019. The coverage for the pentavalent vaccine at 6 and 10 weeks was lowest in February and September. The pentavalent vaccine DOR pattern showed the lowest in February with value of 0% and the highest in June with 12%. Except for May and June, the Pentavalent vaccine DORs for all other months were <10%. February 2019 had the lowest measles coverage. Conclusion: Our study demonstrated that the integration of RI into SIAs could improve RI coverage. and potentially reduce DOR, especially when the integration is of good quality and conducted at short and regular intervals. Although SIAs are instrumental at increasing RI coverage, the disruption of RI services may occur due to overlapping resources and poor planning. Therefore, SIAs should be adequately planned by program managers to strengthen RI service delivery during the SIAs implementation.

Significance of a social mobilization intervention for engaging communities in polio vaccination campaigns: Evidence from CORE Group Polio Project, Uttar Pradesh, India

Background

Globally, community engagement is an integral part of most public health programs and the social mobilization (SM) intervention of India’s polio eradication program is one such example that contributed to eliminating polio from the country. CORE Group Polio Project (CGPP), a partner of Uttar Pradesh (U.P.) SM Network executed its activities through a network of social mobilizers called Community Mobilization Coordinators (CMCs). These were deployed in polio high risk areas to perform awareness generation and trust-building activities with communities and achieved high coverage of polio vaccination during Supplementary Immunization Activity campaigns (SIAs). This paper measures the extent and outcomes of CMC community engagement in SM interventions and polio SIAs.

Methods

This study used secondary, cluster-level data from Management Information System of CGPP India, including 52 SIAs held between January 2008 to September 2017 in 56 blocks/polio planning units, covering 12 districts of U.P. We used five indicators that reflected community engagement in polio SIAs and constructed a Community Engagement Index (CEI). Further, we estimated the difference in the CEI between CMC and non-CMC areas, using Generalized Estimating Equations (GEE) and also estimated treatment effects through Difference-in-Differences (DID) method using STATA.

Results

Overall, 78.6% (95% confidence interval (CI) = 78.3, 78.8) of families from the study area were engaged in the polio SIAs and the extent of community engagement increased over time. The mean CEI of entire study period in CMC areas (85.8%; 95% CI = 85.6, 86.0) was significantly higher (P < 0.001) than that of non-CMC areas (71.3%; 95% CI = 71.1, 71.5). Over time, the SM intervention led to at least 11 percentage points increase in the CEI of CMC areas with about 17% of this achievement attributable to CGPP India’s SM efforts.

Conclusions

The study findings suggest that intensive social mobilization efforts can significantly increase the extent of community engagement. The community engagement learnings of polio SM Network may be useful to achieve the desired outcomes of public health programs such as the National Health Mission (NHM) of India, that serves communities for multiple health issues.

Trend and determinants of complete vaccination coverage among children aged 12-23 months in Ghana: Analysis of data from the 1998 to 2014 Ghana Demographic and Health Surveys

BACKGROUND

Vaccination is proven to be one of the most cost-effective measures adopted to improve the health of children globally. Adhering to vaccines for children has the propensity to prevent about 1.5 million annual child deaths globally. This study sought to assess the trend and determinants of complete vaccination coverage among children aged 12-23 months in Ghana.

MATERIALS AND METHODS

The study was based on data from four rounds of the Ghana Demographic and Health Survey (GDHS 1998, 2003, 2008, and 2014). Information on 5,119 children aged 12-23 months were extracted from the children's files. Both bivariate and multivariate analyses were conducted to assess the factors associated with complete vaccination and statistical significance was pegged at p<0.05.

RESULTS

We found that complete vaccination coverage increased from 85.1% in 1998 to 95.2% in 2014. Children whose mothers were in rural areas [aOR = 0.45; CI = 0.33-0.60] had lower odds of getting complete vaccination, compared to those whose mothers were in urban areas. Also, children whose mothers had a secondary level of education [aOR = 1.87; CI = 1.39-2.50] had higher odds of receiving complete vaccination, compared to those whose mothers had no formal education. Children whose mothers were either Traditionalists [aOR = 0.60; CI = 0.42-0.84] or had no religion [aOR = 0.58, CI = 0.43-0.79] had lower odds of receiving complete vaccination, compared to children whose mothers were Christians.

CONCLUSION

The study revealed that there has been an increase in the coverage of complete vaccination from 1998 to 2014 in Ghana. Mother's place of residence, education, and religious affiliation were significantly associated with full childhood vaccination. Although there was an increase in complete childhood vaccination, it is imperative to improve health education and expand maternal and child health services to rural areas and among women with no formal education to further increase complete vaccination coverage in Ghana.

Use of Social Mobilization and Community Mobilizers by Non-governmental Health Organizations in Malawi to Support the Eradication of Polio, Improve Routine Immunization Coverage, and Control Measles and Neonatal Tetanus

Seventy-five percent of children aged 12-23 months in Malawi have received all eight basic vaccinations-still leaving many children at risk. The Malawi Expanded Program on Immunization comprehensive Multi-Year Plan 2016-2020 reveals several challenges impeding immunization and disease surveillance efforts, such as the fact that non-governmental health organizations (NGHOs) and communities are minimally included in the planning, implementation, and monitoring of these activities. This article examines the extent to which NGHOs are promoting the use of social mobilization (SM) and community mobilizers (CMs) for sharing health information related to the eradication of polio, the importance of routine immunization, and the control of measles and neonatal tetanus. Data collection involved document analysis and interviews with 11 organizations in Malawi whose work contributes to the eradication of polio and control of measles and neonatal tetanus. Content analysis was used to analyze the qualitative data, whereas descriptive statistics were used to analyze the quantitative data. Non-governmental health organizations use a variety of approaches for SM, including mass media campaigns (radio and printed booklets), local skits and dramas, and home visits. Most NGHOs use training workshops and opinion leaders to impart knowledge and skills to CMs on immunization to eradicate polio and to control measles and neonatal tetanus. Major challenges faced by the NGHOs include negative attitudes toward campaigns and demotivation of CMs due to lack of financial incentives. The article concludes with a discussion of approaches to strengthen SM and the role of CMs by NGHOs.

Effectiveness of a Census-Based Management Information System for Guiding Polio Eradication and Routine Immunization Activities: Evidence from the CORE Group Polio Project in Uttar Pradesh, India

Census-based management information systems (CB-MISs) bring strength and power to public health programs by providing current information about everyone in the population covered by the program. Such a system has been developed by the CORE Group Polio Project (CGPP) in India. This article assesses the effectiveness of the CGPP CB-MIS in the management of social and behavioral change interventions. It also assesses the feasibility of the CB-MIS for vital events registration. We describe the procedures of the CB-MIS and measure the outcomes of the CGPP by observing the trends of vaccination coverage in CGPP catchment areas over time. We also compute vital statistics from births and deaths registered through the CGPP CB-MIS and compare them with the estimates from the Civil Registration System of India using statistics from India's Sample Registration System in Uttar Pradesh as the "gold standard." The CB-MIS has helped the CGPP to manage its social and behavior change communication interventions effectively, and it has contributed to the increase in polio vaccine coverage facilitated by the CGPP. We also estimate that the CGPP's CB-MIS has registered 86% of births and 98% of infant deaths, a much higher level of registration than has been achieved by the Civil Registration System for the entire state of Uttar Pradesh. The CB-MIS has helped to make it possible for community-based health workers to make behavioral diagnoses of barriers to immunization and to overcome them. The CB-MIS also provides a robust platform for community-based health workers to register vital events.

The CORE Group Polio Project: An Overview of Its History and Its Contributions to the Global Polio Eradication Initiative

The CORE Group Polio Project (CGPP) has contributed to polio eradication by successfully engaging civil society, particularly the non-governmental organization (NGO) community. This engagement, which began with a grant from the U.S. Agency for International Development in 1999, has contributed to improvements in routine immunization programs, polio campaign quality, and surveillance for acute flaccid paralysis in many challenging geographic areas. The CGPP has worked closely with polio eradication partners in a collaborative and supportive role. The CGPP has focused largely on high-risk areas with marginalized or hard-to-reach populations where health systems and immunization programs have also been weak and where transmission of poliovirus had not been stopped. The CGPP has engaged local civic leaders and communities in ways to complement top-down vertical efforts of ministries of health and other partners in the Global Polio Eradication Initiative. The CGPP has developed innovative strategies to detect cases using community-based surveillance, promoted independent campaign monitoring, established cross-border initiatives, and developed a strong and creative cadre of community mobilizers to track missed children and deliver behavior change education. Many of the innovations and approaches that the CGPP helped to develop are now being replicated by governments and international agencies to tackle other public health priorities in underserved and marginalized communities around the world. This article is the first in a series of articles describing the work of the CGPP. Because the article describes the work of more than 40 NGOs in 11 countries over 20 years, it provides only an overview, leaving many important details and variations of the CGPP's work to be described elsewhere, including in other articles included in this series.

Achieving high uptake of human papillomavirus vaccination in Malaysia through school-based vaccination programme

BACKGROUND

In 2006, 4 years of planning was started by the Ministry of Health, Malaysia (MOH), to implement the HPV (human papillomavirus) vaccination programme. An inter-agency and multi-sectoral collaborations were developed for Malaysia's HPV school-based immunisation programme. It was approved for nationwide school base implementation for 13-year-old girls or first year secondary students in 2010. This paper examines how the various strategies used in the implementation over the last 7 years (2010-2016) that unique to Malaysia were successful in achieving optimal coverage of the target population.

METHODS

Free vaccination was offered to school girls in secondary school (year seven) in Malaysia, which is usually at the age of 13 in the index year. All recipients of the HPV vaccine were identified through school enrolments obtained from education departments from each district in Malaysia. A total of 242,638 girls aged between 12 to 13 years studying in year seven were approached during the launch of the program in 2010. Approximately 230,000 girls in secondary schools were offered HPV vaccine per year by 646 school health teams throughout the country from 2010 to 2016.

RESULTS

Parental consent for their daughters to receive HPV vaccination at school was very high at 96-98% per year of the programme. Of those who provided consent, over 99% received the first dose each year and 98-99% completed the course per year. Estimated population coverage for the full vaccine course, considering also those not in school, is estimated at 83 to 91% per year. Rates of adverse events reports following HPV vaccination were low at around 2 per 100,000 and the majority was injection site reactions.

CONCLUSION

A multisectoral and integrated collaborative structure and process ensured that the Malaysia school-based HPV immunisation programme was successful and sustained through the programme design, planning, implementation and monitoring and evaluation. This is a critical factor contributing to the success and sustainability of the school-based HPV immunisation programme with very high coverage.

Demand-side determinants of timely vaccination of oral polio vaccine in social mobilization network areas of CORE Group polio project in Uttar Pradesh, India

Background

Children who receive all doses of scheduled vaccines reduce their susceptibility to vaccine-preventable diseases. In India, full immunization coverage has increased significantly. However, only a small proportion of children are immunized on time. Globally, studies on factors affecting coverage of childhood immunization have found a significant impact by demand and supply-side determinants. This paper explores the demand-side determinants of timely immunization of the third dose of oral polio vaccine (OPV3) among children aged 6–11 months in the catchment areas of CORE Group Polio Project India.

Methods

We analyzed secondary de-identified data from a household level ‘Doers and Non-doers survey’ conducted in 2015. Determinants of timely OPV3 immunization were identified by modeling the characteristics of index children and survey respondents, surveyed households, respondents’ media habits, their exposure to immunization services and perceptions towards child immunization, through a multinomial regression analysis.

Results

The eight demand-side predictors based on the background characteristics and perceptions of caregivers determined timely vaccination of OPV3. The strongest predictor of timely OPV3 immunization was found to be the fathers’ educational level. Children of uneducated or lesser educated fathers had increased odds of not receiving the OPV1 vaccination, as compared to children of more educated fathers (OR > 10). Respondents who strongly perceived other (non-health) benefits of child immunization were three times more likely to timely vaccinate their children than those who do not. Furthermore, mothers who disagreed with the positive attributes of child immunization were 25 times more likely to delay or not to take their children for OPV immunization on time.

Conclusions

This study found eight essential factors that are responsible for timely OPV3. Despite limitations in data collection and analysis, immunization programs in India could use the eight identified demand-side determinants of timeliness and tailor communication strategies accordingly. We suggest that program communication efforts be directed at male community members; such messaging should address parents’ perceptions of non-health benefits and stress the positive attributes of child immunization. Further investigation would be helpful to assess the various risk factors of under-vaccination as well as vaccinators’ understating about timely immunization.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3129-2) contains supplementary material, which is available to authorized users.

Experiences and Lessons From Polio Eradication Applied to Immunization in 10 Focus Countries of the Polio Endgame Strategic Plan

Nine polio areas of expertise were applied to broader immunization and mother, newborn and child health goals in ten focus countries of the Polio Eradication Endgame Strategic Plan: policy & strategy development, planning, management and oversight (accountability framework), implementation & service delivery, monitoring, communications & community engagement, disease surveillance & data analysis, technical quality & capacity building, and partnerships. Although coverage improvements depend on multiple factors and increased coverage cannot be attributed to the use of polio assets alone, 6 out of the 10 focus countries improved coverage in three doses of diphtheria tetanus pertussis containing vaccine between 2013 and 2015. Government leadership, evidence-based programming, country-driven comprehensive operational annual plans, community partnership and strong accountability systems are critical for all programs and polio eradication has illustrated these can be leveraged to increase immunization coverage and equity and enhance global health security in the focus countries.

Legacy of Polio-Use of India's Social Mobilization Network for Strengthening of the Universal Immunization Program in India

The Social Mobilization Network (SMNet) has been lauded as one of the most successsful community engagement strategies in public health for its role in polio elimination in India. The UNICEF-managed SMNet was created as a strategy to eradicate polio by engaging >7000 frontline social mobilizers to advocate for vaccination in some of the most underserved, marginalized, and at-risk communities in India. This network focused initially on generating demand for polio vaccination but later expanded its messaging to promote routine immunization and other health and sanitation interventions related to maternal and children’s health. As an impact of the network’s interventions, in collaboration with other eradication efforts, these high-risk pockets witnessed an increase in full routine immunization coverage. The experience of the SMNet offers lessons for health-system strengthening for social mobilization and promoting positive health behaviors for other priority health programs like the Universal Immunization Program.

Vaccine coverage and adherence to EPI schedules in eight resource poor settings in the MAL-ED cohort study

BACKGROUND

Launched in 1974, the Expanded Program on Immunization (EPI) is estimated to prevent two-three million deaths annually from polio, diphtheria, tuberculosis, pertussis, measles, and tetanus. Additional lives could be saved through better understanding what influences adherence to the EPI schedule in specific settings.

METHODS

The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) study followed cohorts in eight sites in South Asia, Africa, and South America and monitored vaccine receipt over the first two years of life for the children enrolled in the study. Vaccination histories were obtained monthly from vaccination cards, local clinic records and/or caregiver reports. Vaccination histories were compared against the prescribed EPI schedules for each country, and coverage rates were examined in relation to the timing of vaccination. The influence of socioeconomic factors on vaccine timing and coverage was also considered.

RESULTS

Coverage rates for EPI vaccines varied between sites and by type of vaccine; overall, coverage was highest in the Nepal and Bangladesh sites and lowest in the Tanzania and Brazil sites. Bacillus Calmette-Guérin coverage was high across all sites, 87-100%, whereas measles vaccination rates ranged widely, 73-100%. Significant delays between the scheduled administration age and actual vaccination date were present in all sites, especially for measles vaccine where less than 40% were administered on schedule. A range of socioeconomic factors were significantly associated with vaccination status in study children but these results were largely site-specific.

CONCLUSIONS

Our findings highlight the need to improve measles vaccination rates and reduce delayed vaccination to achieve EPI targets related to the establishment of herd immunity and reduction in disease transmission.

Winning the battle against the scourge of poliomyelitis in the African Region

INTRODUCTION

Recently we have recorded some progress against the transmission of poliovirus in the African Region. This is attributable to a number of factors, including commitment of global partnerships against polio, improvement of existing strategies as well as a number of innovations in response to the disease in the Region.

METHODS

The WHO Regional Office in Africa documented these practices that led to the noticeable progress in the polio eradication initiative in the African Region, as lessons learnt and as part of polio legacy planning. The documentation exercise covered eight countries, namely Angola, Chad, Cote d'Ivoire, Democratic Republic of Congo, Ethiopia, Nigeria, Tanzania and Togo.

RESULTS

A number of practices were identified. Some of these practices cut across countries while others were peculiar to specific countries. We have thus developed some manuscripts to capture these practices for publication in scientific journal so as to place them in the public domain for use.

CONCLUSION

It is hoped that these practices will be deployed to other public health programmes in the Region and beyond.

Documentation of polio eradication initiative best practices: Experience from WHO African Region

BACKGROUND

The African Region is set to achieving polio eradication. During the years of operations, the Polio Eradication Initiative [PEI] in the Region mobilized and trained tremendous amount of manpower with specializations in surveillance, social mobilization, supplementary immunization activities [SIAs], data management and laboratory staff. Systems were put in place to accelerate the eradication of polio in the Region. Standardized, real-time surveillance and response capacity were established. Many innovations were developed and applied to reaching people in difficult and security challenged terrains. All of these resulted in accumulation of lessons and best practices, which can be used in other priority public health intervention if documented.

METHODS

The World Health Organization Regional Office for Africa [WHO/AFRO] developed a process for the documentation of these best practices, which was pretested in Uganda. The process entailed assessment of three critical elements [effectiveness, efficiency and relevance] five aspects [ethical soundness, sustainability, involvement of partners, community involvement, and political commitment] of best practices. A scored card which graded the elements and aspects on a scale of 0-10 was developed and a true best practice should score >50 points. Independent public health experts documented polio best practices in eight countries in the Region, using this process. The documentation adopted the cross-sectional design in the generation of data, which combined three analytical designs, namely surveys, qualitative inquiry and case studies. For the selection of countries, country responses to earlier questionnaire on best practices were screened for potential best practices. Another criterion used was the level of PEI investment in the countries.

RESULTS

A total of 82 best practices grouped into ten thematic areas were documented. There was a correlation between the health system performances with DPT3 as proxy, level of PEI investment in countries with number of best practice. The application of the process for the documentation of polio best practices in the African Region brought out a number of advantages. The triangulation of data collected using multiple methods and the collection of data from all levels of the programme proved useful as it provided opportunity for data verification and corroboration. It also helped to overcome some of the data challenge.

Polio eradication in the African Region on course despite public health emergencies

The World Health Organization, African Region is heading toward eradication of the three types of wild polio virus, from the Region. Cases of wild poliovirus (WPV) types 2 and 3 (WPV2 and WPV3) were last reported in 1998 and 2012, respectively, and WPV1 reported in Nigeria since July 2014 has been the last in the entire Region. This scenario in Nigeria, the only endemic country, marks a remarkable progress. This significant progress is as a result of commitment of key partners in providing the much needed resources, better implementation of strategies, accountability, and innovative approaches. This is taking place in the face of public emergencies and challenges, which overburden health systems of countries and threaten sustainability of health programmes. Outbreak of Ebola and other diseases, insecurity, civil strife and political instability led to displacement of populations and severely affected health service delivery. The goal of eradication is now within reach more than ever before and countries of the region should not relent in their efforts on polio eradication. WHO and partners will redouble their efforts and introduce better approaches to sustain the current momentum and to complete the job. The carefully planned withdrawal of oral polio vaccine type II (OPV2) with an earlier introduction of one dose of inactivated poliovirus vaccine (IPV), in routine immunization, will boost immunity of populations and stop cVDPVs. Environmental surveillance for polio viruses will supplement surveillance for AFP and improve sensitivity of detection of polio viruses.

Does introducing an immunization package of services for migrant children improve the coverage, service quality and understanding? An evidence from an intervention study among 1548 migrant children in eastern China

BACKGROUND

An EPI (Expanded Program on Immunization) intervention package was implemented from October 2011 to May 2014 among migrant children in Yiwu, east China. This study aimed to evaluate its impacts on vaccination coverage, maternal understanding of EPI and the local immunization service performance.

METHODS

A pre- and post-test design was used. The EPI intervention package included: (1) extending the EPI service time and increasing the frequency of vaccination service; (2) training program for vaccinators; (3) developing a screening tool to identify vaccination demands among migrant clinic attendants; (4) Social mobilization for immunization. Data were obtained from random sampling investigations, vaccination service statistics and qualitative interviews with vaccinators and mothers of migrant children. The analysis of quantitative data was based on a "before and after" evaluation and qualitative data were analyzed using content analysis.

RESULTS

The immunization registration (records kept by immunization clinics) rate increased from 87.4 to 91.9% (P = 0.016) after implementation of the EPI intervention package and the EPI card holding (EPI card kept by caregivers) rate increased from 90.9 to 95.6% (P = 0.003). The coverage of fully immunized increased from 71.5 to 88.6% for migrant children aged 1-4 years (P < 0.001) and increased from 42.2 to 80.5% for migrant children aged 2-4 years (P < 0.001). The correct response rates on valid doses and management of adverse events among vaccinators were over 90% after training. The correct response rates on immunization among mothers of migrant children were 86.8-99.3% after interventions.

CONCLUSION

Our study showed a substantial improvement in vaccination coverage among migrant children in Yiwu after implementation of the EPI intervention package. Further studies are needed to evaluate the cost-effectiveness of the interventions, to identify individual interventions that make the biggest contribution to coverage, and to examine the sustainability of the interventions within the existing vaccination service delivery system in a larger scale settings or in a longer term.

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.