Impact of high-intensity polio eradication activities on children's routine immunization status in Northern India

Technologies for strengthening immunization coverage in India: a systematic review

Background

Immunization coverage varies across India in different settings, geographic areas and populations. Technologies for improving immunization access can reduce disparities in coverage. This systematic review, which follows PRISMA guidelines, aims to examine the technologies for strengthening immunization coverage in India.

Methods

Studies published between January 1, 2011 and July 31, 2021 were searched in Medline (through PubMed), Cochrane Library and Google Scholar. All observational and experimental studies, except qualitative studies, were included. Studies published in the English language and related to technologies for strengthening immunization, conducted on children, pregnant women, adults, elderly, healthcare personnel, caregivers and vulnerable populations across all Indian settings were included. Non-English articles, protocols, commentaries, letters, abstracts, correspondence, opinion articles, modelling, narrative and systematic reviews were excluded. Two reviewers screened studies independently, extracted data in a standardized sheet and appraised the study quality using the Mixed Methods Appraisal Tool. The primary outcome was technologies that improved immunization coverage. The protocol is registered with OSF (https://osf.io/r42gm).

Findings

6592 titles and abstracts were screened, and data extracted from 23 India-specific studies. Quality of 22/23 studies was average or above. Technologies identified included reminder systems, capacity building, community engagement and wearable technologies. Automated incentivised mobile phone reminders, immunization due-list, computerized data tracking, community mobilization and campaigns improved vaccine coverage, although effectiveness of some varied viz., reminder systems, and across states. Newer technologies included the Jyotigram Yojana, Digital Near-field Communication Pendants, "Reaching Every District" Programme and the "My Village My Home" tool.

Interpretation

Technologies for improving immunization systems, capacity building and community engagement were effective. Newer technologies on vaccine delivery, mapping and cold chain logistics were not evaluated in India or were ineffective. There were limited studies in populations other than children and pregnant women. Future work is needed to evaluate the effectiveness of identified technologies across diverse settings.

Funding

No funding was received for preparing this manuscript.

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.

Impact and effect mechanisms of mass campaigns in resource-constrained health systems: quasi-experimental evidence from polio eradication in Nigeria

Background

Mass campaigns are a key strategy for delivering life-saving interventions under Global Health Initiatives, especially in weak health system contexts. They are frequently designed parallel to the health system to rapidly achieve programme targets such as vaccination coverage, but we lack quantitative evidence demonstrating their impact and effect mechanisms on health system performance at sub-/national level. This longitudinal study responds to this gap through an analysis of polio eradication campaigns in Nigeria.

Methods

Using four rounds of Demographic and Health Surveys in Nigeria between October 2000 and December 2017, we created a longitudinal dataset containing 88 881 under-5 children/pregnancies. We estimated the relationships between individuals’ campaign exposure and health system performance indices (full RI schedule attainment, maternal healthcare services utilisation and child survival) using multilevel, mixed-effects regression models applied nationally and stratified by the six geopolitical zones in Nigeria.

Results

Nationally, high-frequency mass campaigns had detrimental health systems effects that potentially left 3.6 million children deprived of full immunisation. The frequency of campaigns was most concentrated in regions with weak health systems, where the operations of RI were disrupted, alongside negative effects on child survival and institutional delivery. In contrast, regions with relatively strong health systems and few campaigns experienced beneficial effects on maternal healthcare service utilisation.

Conclusions

As we provide evidence that well-functioning health systems can benefit from mass campaigns under Global Health Initiatives, our work also challenges the established wisdom to intensify mass campaigns in weaker health systems to bypass service provision bottlenecks. Mass campaigns do not inherently benefit or damage a health system, but frequent campaigns in weak health system contexts can impede service provision. We call for an additional burden of proof and active efforts to integrate mass campaigns into routine health services by harmonising implementation plans and service delivery in weak health system contexts.

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.

Effect of reliable electricity on health facilities, health information, and child and maternal health services utilization: evidence from rural Gujarat, India

BACKGROUND

Reliable basic infrastructure, particularly electricity, is a critical enabling factor in improving health systems and consequently achieving the health sustainable development goals (SDGs). Yet, there is no systematic and rigorous study examining the effect of reliable electricity on health systems in a developing country context. In this study, we examine the effect of Jyotigram Yojana (JGY), a rural electrification program providing 24-h electricity to rural non-agricultural users in Gujarat, India, on core components of health systems including health facilities, health information, and health services utilization.

METHODS

We match data from the District Level Household and Facility Survey (DLHS-II and DLHS-III) and administrative data from electricity distribution companies on JGY implementation. Matching survey data with administrative data allows us to precisely identify the relevant sample from Gujarat for our data analysis. We then apply a difference-in-differences framework to address potential bias in JGY implementation by comparing the sample from Gujarat (treatment group) with that from Maharashtra (control group). Our key independent variable is a dummy indicating JGY implementation, which operationalizes access to reliable electricity. It takes value 1 if the PHC/eligible woman/child is located or residing in the state of Gujarat and 0 if located or residing in the state of Maharashtra. Our outcome variables cover three core components of health systems-health facilities, health information, and child and maternal health services utilization. Each outcome is a binary variable. We therefore estimate probit models with appropriate control variables.

RESULTS

We find that JGY implementation significantly improved the operational capacity of health facilities, in particular primary health centers (PHCs), by increasing the availability and functionality of a wide range of essential devices and equipment. JGY also significantly increased access to health information through television. Further, JGY increased utilization of health services; in particular, it increased the probability of children receiving critical vaccinations and pregnant women receiving antenatal care. Our results are robust to alternate specifications and analysis using alternate data.

CONCLUSION

Reliable electricity can be an effective tool in improving core components of health systems. In addition to targeting direct factors within the health systems such as health workforce and health financing, investments in supporting infrastructure are warranted to achieve the health SDGs.

The impact of supplementary immunization activities on routine vaccination coverage: An instrumental variable analysis in five low-income countries

Background

Countries deliver vaccines either through routine health services or supplementary immunization activities (SIAs), usually community-based or door-to-door immunization campaigns. While SIAs have been successful at increasing coverage of vaccines in low- and middle-income countries, they may disrupt the delivery of routine health services. We examine the impact of SIAs on routine vaccine coverage in five low-income countries.

Methods

Data on the number and timing of SIAs conducted in various countries was compiled by WHO and obtained through UNICEF. Information on the coverage of vaccines not targeted by SIAs (e.g., DPT) was extracted from the Demographic and Health Surveys. We focus on SIAs that took place between 1996 and 2013 in Bangladesh, Senegal, Togo, Gambia, and Cote d’Ivoire, and examine outcomes for children aged 12–59 months. To avoid biases resulting from non-random placement and timing of SIAs, we use age of a child at her first SIA as an instrumental variable for total exposure to SIAs.

Results

We find that SIA exposure reduced the likelihood of receiving routine vaccines in all the countries included in the study; the coefficients of interest are however statistically insignificant for Gambia and Cote d’Ivoire. In countries that witnessed statistically significant SIA-induced declines in the likelihood of obtaining DPT 3, measles as well as BCG, reductions ranged from 1.3 percentage points (Senegal) to 5.5 percentage points (Bangladesh).

Conclusion

SIA exposure reduced routine vaccination rates in study countries. Efforts should be made to limit the detrimental impact of SIAs on the services provided by routine health systems.