African vaccination week as a vehicle for integrated health service delivery

Group-based trajectory models of integrated vaccine delivery and equity in low- and middle-income countries

BACKGROUND

Integrated vaccine delivery - the linkage of routine vaccination with provision of other essential health services - is a hallmark of robust primary care systems that has been linked to equitable improvements in population health outcomes.

METHODS

We gathered longitudinal data relating to routine immunization coverage and vaccination equity in 78 low- and middle-income countries that have ever received support from Gavi, the Vaccine Alliance, using multiple imputation to handle missing values. We then estimated several group-based trajectory models to describe the relationship between integrated vaccine delivery and vaccination equity in these countries. Finally, we used multinomial logistic regression to identify predictors of group membership.

RESULTS

We identified five distinct trajectories of geographic vaccination equity across both the imputed and non-imputed datasets, along with two and four trajectories of socioeconomic vaccination equity in the imputed and non-imputed datasets, respectively. Integration was associated with reductions in the slope index of inequality of measles vaccination in the countries analyzed. Integration was also associated with an increase in the percentage of districts reporting high measles vaccination coverage.

CONCLUSIONS

Integrated vaccine delivery is most strongly associated with improvements in vaccination equity in settings with high baseline levels of inequity. Continued scholarship is needed to further characterize the relationship between integration and health equity, as well as to improve measurement of vaccination coverage and integration.

A scoping review on integrated health campaigns for immunization in low- and middle-income countries

Health campaign integration is a key implementation strategy outlined by the World Health Organization to achieve universal health coverage. This scoping review synthesizes the evidence on Integrated Health Campaigns (IHC) in the field of immunization in low- and middle-income countries (LMICs) regarding the most common strategies, facilitators and barriers. Four reviewers followed a systematic approach to identify, screen and analyse relevant articles. The team used three search engines (PubMed, Scopus and Google Scholar) to identify peer-reviewed journal articles as well as select institutional websites for grey literature publications. Full-text articles using any study design and across any time frame were included. Data were extracted following a predefined matrix, analysed deductively and presented in a narrative synthesis. Thirty articles (20 academic and 10 grey) were included in the final review. All studies included identified IHCs as effective when planning or implementation is integrated. The common strategies were: using resources efficiently in remote locations; using national immunization days to maximize impact; targeting specific age groups by selecting intervention sites that are frequented by that age group; building community ownership over the integrated program; and integrating programs that already share common elements. The key facilitators were: closing the gap between services and communities; planning, coordination and resource management both before and during integration; cost-effectiveness; and utilization of pre-existing infrastructure. The common barriers included seemingly optimized initial cost to appear feasible only in the short term and additional responsibilities on the field staff. This review finds IHCs a common practice in immunization and identifies gaps in evidence on evaluation; indicating the need for additional research. Strong evidence accounts IHCs to increase coverage, improve community acceptance of health services and strengthen the community models of health service delivery.

Lessons Learned From Integrating Infant and Young Child Feeding Counseling and Iron-Folic Acid Distribution Into Routine Immunization Services in Ethiopia

Immunization programs reach more children and communities than any other health intervention, thus making immunization a promising platform for integrating other essential health services. There is a dearth of literature on integrating nutrition interventions, such as infant and young child feeding (IYCF) counseling and iron-folic acid (IFA) supplementation, into routine immunization services.To address this evidence gap, a 15-month pilot study (August 2019 to November 2020) tested the feasibility of integrating IYCF counseling and IFA supplement distribution into immunization service delivery in Ethiopia. The interventions focused on joint microplanning for integrated services (including estimating target populations for all services), revising client flows for service delivery, and providing on-the-job support to HWs for implementing and monitoring integrated service delivery.Findings suggest that planning for and delivering IYCF counseling and IFA supplementation with immunization services is feasible. Integrating these services provided opportunities for collaborative planning and enabled health workers (HWs) to offer multiple services to clients through 1 interaction. However, HWs felt that additional human resources were needed to manage integrated services, especially during integrated outreach and mobile service delivery. HWs also reported that communities appreciated accessing 2 services in 1 visit but expressed reservations about the longer wait times.Countries may consider expanding fixed and outreach immunization services to provide integrated service delivery provided that it is feasible, sustainable, of high quality, and incorporates the careful planning, follow-up, and increased human and financial resources needed to reinforce new practices and expand access to a broader array of health services.

The Challenge of Achieving Immunity Through Multiple-Dose Vaccines in Madagascar

Administration of many childhood vaccines requires that multiple doses be delivered within a narrow time window to provide adequate protection and reduce disease transmission. Accurately quantifying vaccination coverage is complicated by limited individual-level data and multiple vaccination mechanisms (routine and supplementary vaccination programs). We analyzed 12,541 vaccination cards from 6 districts across Madagascar for children born in 2015 and 2016. For 3 vaccines-pentavalent diphtheria-tetanus-pertussis-hepatitis B-Haemophilus influenzae type b vaccine (DTP-HB-Hib; 3 doses), 10-valent pneumococcal conjugate vaccine (PCV10; 3 doses), and rotavirus vaccine (2 doses)-we used dates of vaccination and birth to estimate coverage at 1 year of age and timeliness of delivery. Vaccination coverage at age 1 year for the first dose was consistently high, with decreases for subsequent doses (DTP-HB-Hib: 91%, 81%, and 72%; PCV10: 82%, 74%, and 64%; rotavirus: 73% and 63%). Coverage levels between urban districts and their rural counterparts did not differ consistently. For each dose of DTP-HB-Hib, the overall percentage of individuals receiving late doses was 29%, 7%, and 6%, respectively; estimates were similar for other vaccines. Supplementary vaccination weeks, held to help children who had missed routine care to catch up, did not appear to increase the likelihood of being vaccinated. Maintaining population-level immunity with multiple-dose vaccines requires a robust stand-alone routine immunization program.

New vaccine introductions in Africa before and during the decade of vaccines - Are we making progress?

Vaccines are excellent investments with far-reaching rewards beyond individual and population health, but their introduction into national programs has been historically slow in Africa. We provide an overview of the introduction of new and underutilized vaccines in countries of the WHO African Region by 2017, using data from the WHO-UNICEF Joint Reporting Form. By 2017, all 47 countries had introduced vaccines containing hepatitis B (compared to 11% in 2000 and 98% in 2010) and Haemophilus influenzae type b (Hib) (compared to 4% in 2000 and 91% in 2010). The proportion of countries that had introduced other vaccines by 2017 was 83% for pneumococcal conjugate vaccine (PCV) from 7% in 2010, 72% for rotavirus vaccine from 2% in 2010, 55% for the second dose of a measles-containing vaccine (MCV2) (compared to 11% in 2000 and 17% in 2010), and 45% for rubella-containing vaccines (RCV) (compared to 4% in 2000 and 7% in 2010). From 2000 to 2010, there was no significant difference between countries eligible (N = 36) and those not eligible (N = 10) for Gavi support in the introduction of hepatitis B and PCV. However, Gavi eligible countries were more likely to introduce Hib and non-Gavi eligible countries were more likely to introduce MCV2 and RCV. From 2010 to 2017, the only significant differences that remained between the two groups of countries were with mumps, inactivated polio and seasonal influenza vaccines; which non-Gavi eligible countries were more likely to have introduced. There has been significant progress in the introduction of new childhood vaccines in Africa, mostly driven by Gavi support. As many countries are expected to transition out of Gavi support soon, there is need for countries in the region to identify predictable, reliable and sustainable immunization funding mechanisms. This requires commitments and actions that go beyond the purchase of vaccines.

Inequitable coverage of vitamin A supplementation in Nigeria and implications for childhood blindness

Background

Vitamin A deficiency (VAD) is of major public health significance; it is a risk factor for childhood deaths from diarrhoea and measles in low and middle-income countries and an important cause of preventable childhood blindness in low income countries. Vitamin A supplementation (VAS) is being implemented in many LMICs and high coverage reduces the prevalence of blinding corneal diseases in children. However, national estimates of coverage may not reveal any inequities in intra country coverage. The aim of this study is to assess factors influencing VAS coverage and also assess the relationship between VAS coverage and childhood corneal blindness in Nigeria.

Methods

Data were collected from the Nigeria Demographic and Health Survey (NDHS) 2013 and the published literature on population-based childhood blindness surveys in Nigeria. The main outcome measure was the proportion of eligible children who received VAS in the last 6 months preceding the survey. Study factors comprised a range of socioeconomic, and individual factors. Data were analysed using STATA V.12.1 (Statcorp, Texas). To explore the effects of the independent variables on VAS coverage, bivariate and multivariate regression was done. Variables with p < 0.05 in the final multivariable model were considered as independent factors. For the population-based childhood blindness surveys, aggregated and disaggregated data were used. Causes of blindness were stratified into corneal blindness and ‘others’. Odds ratios were computed to determine the odds of developing corneal blindness in each geopolitical region. Tests of significance were set at the 95% level.

Results

The total VAS coverage in 2013 was 41.5%. VAS coverage was inequitable. Children with very educated mothers (OR 3.27 p < 0.001), from the south-south region (OR 2.38 p < 0.001) or in the highest wealth quintile (OR 2.81 p < 0.001) had higher odds of receiving VAS. The northwest zone had the lowest VAS coverage and the highest prevalence of corneal blindness.

Conclusion

Regional and socioeconomic inequities in VAS exist in Nigeria and these may have grave implications for the causes of childhood blindness. The development and implementation of context specific and effective strategies are needed to reduce these inequities in VAS.

Conduct of vaccination in hard-to-reach areas to address potential polio reservoir areas, 2014-2015

BACKGROUND

The Global Vaccine Action Plan (GVAP) seeks to achieve the total realization of its vision through equitable access to immunization as well as utilizing the immunization systems for delivery of other primary healthcare programs. The inequities in accessing hard-to-reach areas have very serious implications for the prevention and control of vaccine-preventable diseases, especially the polio eradication initiative. The Government of Nigeria implemented vaccination in hard-to-reach communities with support from the World Health Organization (WHO) to address the issues of health inequities in the hard-to-reach communities. This paper documents the process of conducting integrated mobile vaccination in these hard-to-reach areas and the impact on immunization outcomes.

METHODS

We conducted vaccination using mobile health teams in 2311 hard-to-reach settlements in four states at risk of sustaining polio transmission in Nigeria from July 2014 to September 2015.

RESULTS

The oral polio vaccine (OPV)3 coverage among children under 1 year of age improved from 23% at baseline to 61% and OPV coverage among children aged 1-5 years increased from 60 to 90%, while pentavalent vaccine (penta3) coverage increased from 22 to 55%. Vitamin A was administered to 78% of the target population and 9% of children that attended the session were provided with treatment for malaria.

CONCLUSIONS

The hard-to-reach project has improved population immunity against polio, as well as other routine vaccinations and delivery of child health survival interventions in the hard-to-reach and underserved communities.

Five-year experience of African Vaccination Week implemented by the WHO Regional Office

The 5th edition of the African Vaccination Week (AVW) kicked off in Lusaka, Zambia, on 23 April 2016, the same day as did the 4th World Immunization Week (WIW), and vaccination week in other WHO regions. The theme was "Save lives, prevent disabilities, vaccinate!". The aim was to draw attention to the need to attain universal immunization coverage in the African Region by closing the immunization gap, while also celebrating the important polio eradication milestone reached in the African Region. Twenty-eight (59.6%) of the 47 countries in the African Region celebrated the AVW within the regionally set dates of 24th to 30th April 2015. However, given its flexibility, the celebration continued until September in 15 other countries in the Region. Three countries, namely Comoros, Gabon, and Cape Verde did not join the celebration for the 2015 edition of the AVW. Countries used the opportunity to introduce new vaccines into their routine immunization. Populations, hitherto unreached with basic health services were reached with needed services, such as vitamin A supplementation, deworming, and catch up immunization services. The programmes promoted awareness of the benefits of vaccines and the rights of communities to demand vaccines and immunization services to save lives and prevent disabilities. The number of participating countries rose steadily from 40 in 2011 to 43 and 46 countries in 2013 and 2014 respectively. The number ranged from one intervention integrated with AVW in 17 countries to 5 interventions integrated with the AVW in three countries. In 2015, 67.4% of the participating countries integrated other interventions with AVW activities.

The regulation and adoption of health technologies under Brazil's Unified Health System: barriers to access to medicines for diseases of poverty?

The study aimed to examine the regulation and adoption of health technologies for the diseases of poverty in the Brazil's Unified Health System (SUS). An exploratory, descriptive study was conducted between January and May 2016 consisting of the search and analysis of relevant documents on the websites of Brazil's National Health Surveillance Agency, the U.S. Food and Drug Administration (FDA), the European Medicines Agency (EMA), the National Commission for the Adoption of Technologies by the SUS, and Saúde Legis (the Ministry of Health's Legislation System). The 2014 version of the Brazilian National List of Essential Medicines (RENAME, acronym in Portuguese) contained 132 medicines for diseases of poverty. Over one-third of these (49) had only one national producer, while 24 were not registered in the country. The number of medicines contained in the RENAME dedicated to this group of diseases increased by 46% between 2006 and 2014. Despite advances in the regulation and incorporation of technologies by the SUS, given the lack of market interest and neglect of diseases of poverty, the government has a vital role to play in ensuring access to the best available therapies in order to reduce health inequalities. It therefore follows that Brazil needs to improve the regulation of medicines that do not attract market interest.

Youth Group Engagement in Noncompliant Communities During Supplemental Immunization Activities in Kaduna, Nigeria, in 2014

INTRODUCTION

One of the major challenges being faced in the Global Polio Eradication Initiative program is persistent refusal of oral polio vaccine (OPV) and harassment of vaccination team members by youths. The objective of the study was to describe the strategy of collaborating with recognized youth groups to reduce team harassment during vaccination campaigns and improve vaccination coverage in noncompliant communities.

METHODS

We assessed data from polio vaccination activities in OPV-refusing communities in the Igabi and Zaria local government areas (LGAs) of Kaduna State in Nigeria. We evaluated the following factors to determine trends: enhanced independent monitoring data on the proportion of children missed by vaccination activities (hereafter, "missed children"), lot quality assurance surveys, and vaccination team harassment.

RESULTS

The proportion of missed children decreased in both LGAs after the intervention. In Igabi LGA and Zaria LGA, the lowest proportions of missed children before and after the intervention decreased from 7% to 2% and from 5% to 1%, respectively. Lot quality assurance survey trends showed an improvement in immunization coverage 1 year after youth groups' engagement in both LGAs.

CONCLUSIONS

Systematic engagement of youth groups has a great future in polio interruption as we approach the endgame strategy for polio eradication. It promises to be a veritable innovation in reaching chronically missed children in OPV-refusing communities.