Micro-planning for immunization in Kaduna State, Nigeria: Lessons learnt, 2017

Analysis of the impact of COVID-19 pandemic and response on routine childhood vaccination coverage and equity in Northern Nigeria: a mixed methods study

BACKGROUND

Based on 2021 data, Nigeria had the second largest number of zero-dose children globally estimated at over 2.25 million, concentrated in the northern part of the country due to factors some of which are sociocultural. This study analysed the impact of the COVID-19 pandemic and response on childhood vaccination in Northern Nigeria.

METHODS

Using a mixed methods sequential study design in the most populous northern states of Kaduna and Kano, quantitative routine immunisation data for the period 2018-2021 and qualitative data collected through 16 focus group discussions and 40 key informant interviews were used. An adaptation of the socioecological model was used as a conceptual framework. Mean vaccination coverages and test of statistical difference in childhood vaccination data were computed. Qualitative data were coded and analysed thematically.

RESULTS

Mean Penta 1 coverage declined in Kaduna from 69.88% (SD=21.02) in 2018 to 59.54% (SD=19.14%) by 2021, contrasting with Kano where mean Penta 1 coverage increased from 51.87% (SD=12.61) to 56.32% (SD=17.62%) over the same period. Outreaches and vaccination in urban areas declined for Kaduna state by 10% over the pandemic period in contrast to Kano state where it showed a marginal increase. The two states combined had an estimated 25% of the country's zero-dose burden in 2021. Lockdowns, lack of transport and no outreaches which varied across the states were some of the factors mentioned by participants to have negatively impacted childhood vaccination. Special vaccination outreaches were among the recommendations for ensuring continued vaccination through a future pandemic.

CONCLUSION

While further interrogating the accuracy of denominator estimates for the urban population, incorporating findings into pandemic preparedness and response will ensure uninterrupted childhood vaccination during emergencies. Addressing the identified issues will be critical to achieving and sustaining universal childhood vaccination in Nigeria.

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 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.

A systems map of the economic considerations for vaccination: Application to hard-to-reach populations

BACKGROUND

Understanding the economics of vaccination is essential to developing immunization strategies that can be employed successfully with limited resources, especially when vaccinating populations that are hard-to-reach.

METHODS

Based on the input from interviews with 24 global experts on immunization economics, we developed a systems map of the mechanisms (i.e., necessary steps or components) involved in vaccination, and associated costs and benefits, focused at the service delivery level. We used this to identify the mechanisms that may be different for hard-to-reach populations.

RESULTS

The systems map shows different mechanisms that determine whether a person may or may not get vaccinated and the potential health and economic impacts of doing so. The map is divided into two parts: 1) the costs of vaccination, representing each of the mechanisms involved in getting vaccinated (n = 23 vaccination mechanisms), their associated direct vaccination costs (n = 18 vaccination costs), and opportunity costs (n = 5 opportunity costs), 2) the impact of vaccination, representing mechanisms after vaccine delivery (n = 13 impact mechanisms), their associated health effects (n = 10 health effects for beneficiary and others), and economic benefits (n = 13 immediate and secondary economic benefits and costs). Mechanisms that, when interrupted or delayed, can result in populations becoming hard-to-reach include getting vaccines and key stakeholders (e.g., beneficiaries/caregivers, vaccinators) to a vaccination site, as well as vaccine administration at the site.

CONCLUSION

Decision-makers can use this systems map to understand where steps in the vaccination process may be interrupted or weak and identify where gaps exist in the understanding of the economics of vaccination. With improved understanding of system-wide effects, this map can help decision-makers inform targeted interventions and policies to increase vaccination coverage in hard-to-reach populations.

An epidemiological investigation of the 2019 suspected pertussis outbreak in northwestern Nigeria

Introduction:

In 2019, we investigated the profile of the cases and controls and the determinants of pertussis transmission in Kebbi State, Northwestern Nigeria, to inform better immunization and surveillance strategies.

Methods:

Community-based unmatched case–control study and review of the 2019 pertussis routine surveillance data in the affected settlements in the state were conducted. A total of 52 suspected cases of pertussis and 107 control from two local government areas in Kebbi State were recruited. Data were analyzed using descriptive and inferential statistics.

Results:

The highest attack rate was observed among between 1- and 4-year age group followed by children less than 1-year old, and the least attack rate was among those above 15 years. The overall attack rate and the case fatality rate were 2.10% and 0.10%, respectively. A higher attack rate was observed among women, whereas the case fatality rate was more among males. From the community survey, we observed that the cases were less likely to have pertussis vaccination history (adjusted odds ratio = 0.28, 95% confidence interval = 0.11–0.74) compared with the controls. Knowing pertussis prevention methods were found protective for pertussis transmission (adjusted odds ratio = 0.14, 95% confidence interval = 0.04–0.45).

Conclusion:

This study showed the vulnerability of children under 5 years, especially under 1 year, to vaccine-preventable diseases in rural populations, where “real” immunization coverage is sub-optimal, and the dominant socio-demographic factors are supportive of disease transmission. We found immunization and knowledge of the preventive measures to be protective against pertussis outbreaks. Therefore, routine immunization services must be intensified to improve coverage and prevent future pertussis outbreak(s).

Application of the Geographic Information System (GIS) in immunisation service delivery; its use in the 2017/2018 measles vaccination campaign in Nigeria

BACKGROUND

As global effort is made towards measles elimination, the use of innovative technology to enhance planning for the campaign has become critical. GIS technology has been applied to track polio vaccination activities in Nigeria with encouraging outcomes. Despite numerous measles vaccination campaigns after the first catch up campaign in 2005, sub-optimal outcomes of previous measles supplemental immunization activities necessitated the use of innovative ideas to achieve better outcomes especially when planning for the 2017/2018 measles vaccination campaign. This led to the application of the use of the GIS technology for the Northern states in 2017/2018 campaign. This study is a report of what was achieved with the use of the GIS in the 2017/2018 measles vaccination campaign in Nigeria.

METHODS

GIS generated ward maps were used for the microplanning processes for the 2017/2018 measles vaccination campaign. These ward maps had estimates of the target population by settlements, the number and location of vaccination posts ensuring that a vaccination post is sited within one-kilometer radius of a settlement, and the number of teams needed to support the vaccination campaign as well as the catchment area and daily implementation plans. The ward microplans were verified by checking for accuracy and consistency of the target population, settlements, number of teams, vaccination posts and daily implementation work plans using a standard checklist. The ward maps were deployed into use for the measles vaccination campaign after the state team driven validation and verification by the National team (Government and Partners) RESULTS: The Northern states that applied the GIS technology had a closer operational target population to that on the verified microplan than those of the non-GIS technology states. Greater than 90% of the ward maps had all that is expected in the maps - i.e settlements, target populations, and vaccination posts captured, except Kaduna, Katsina and Adamawa states. Of all enumeration areas sampled during the post-campaign survey in states with GIS ward maps, none had a zero-vaccination coverage of the surveyed children, with the exception of one in Borno state that had security issues. In the post campaign coverage survey, the percentage of responses that gave vaccination post being too far as a reason for non-vaccination of children in the Northern zones that used GIS generated ward maps was less than half the rate seen in the southern zones where the GIS microplanning was not used.

CONCLUSION

The use of GIS-generated wards maps improved the quality of ward micro plans and optimized the placement of vaccination posts, resulting in a significant reduction in zero-dose clusters found during the post campaign coverage survey.

Implementation Science to Respond to the COVID-19 Pandemic

The COVID-19 pandemic continues to expand globally, requiring massive public health responses from national and local governments. These bodies have taken heterogeneous approaches to their responses, including when and how to introduce and enforce evidence-based interventions—such as social distancing, hand-washing, personal protective equipment (PPE), and testing. In this commentary, we reflect on opportunities for implementation science to contribute meaningfully to the COVID-19 pandemic response. We reflect backwards on missed opportunities in emergency preparedness planning, using the example of PPE stockpiling and supply management; this planning could have been strengthened through process mapping with consensus-building, microplanning with simulation, and stakeholder engagement. We propose current opportunities for action, focusing on enhancing the adoption, fidelity, and sustainment of hand washing and social distancing; we can combine qualitative data, policy analysis, and dissemination science to inform agile and rapid adjustment to social marketing strategies to enhance their penetration. We look to future opportunities to enhance the integration of new evidence in decision-making, focusing on serologic and virologic testing systems; we can leverage simulation and other systems engineering modeling to identify ideal system structures. Finally, we discuss the ways in which the COVID-19 pandemic challenges implementation science to become more rapid, rigorous, and nimble in its approach, and integrate with public health practice. In summary, we articulate the ways in which implementation science can inform, and be informed by, the COVID-19 pandemic, looking backwards, proposing actions for the moment, and approaches for the future.

Tracking coverage, dropout and multidimensional equity gaps in immunisation systems in West Africa, 2000-2017

Background

Several West African countries are unlikely to achieve the recommended Global Vaccine Action Plan (GVAP) immunisation coverage and dropout targets in a landscape beset with entrenched intra-country equity gaps in immunisation. Our aim was to assess and compare the immunisation coverage, dropout and equity gaps across 15 West African countries between 2000 and 2017.

Methods

We compared Bacille Calmette Guerin (BCG) and the third dose of diphtheria–tetanus–pertussis (DTP3) containing vaccine coverage between 2000 and 2017 using the WHO and Unicef Estimates of National Immunisation Coverage for 15 West African countries. Estimated subregional median and weighted average coverages, and dropout (DTP1–DTP3) were tracked against the GVAP targets of ≥90% coverage (BCG and DTP3), and ≤10% dropouts. Equity gaps in immunisation were assessed using the latest disaggregated national health survey immunisation data.

Results

The weighted average subregional BCG coverage was 60.7% in 2000, peaked at 83.2% in 2009 and was 65.7% in 2017. The weighted average DTP3 coverage was 42.3% in 2000, peaked at 70.3% in 2009 and was 61.5% in 2017. As of 2017, 46.7% of countries (7/15) had met the GVAP targets on DTP3 coverage. Average weighted subregional immunisation dropouts consistently reduced from 16.4% in 2000 to 7.4% in 2017, meeting the GVAP target in 2008. In most countries, inequalities in BCG, and DTP3 coverage and dropouts were mainly related to equity gaps of more than 20% points between the wealthiest and the poorest, high coverage regions and low coverage regions, and between children of mothers with at least secondary education and those with no formal education. A child’s sex and place of residence (urban or rural) minimally determined equity gaps.

Conclusions

The West African subregion made progress between 2000 and 2017 in ensuring that its children utilised immunisation services, however, wide equity gaps persist.