Strengthening routine immunization services in the Western Pacific through the eradication of poliomyelitis

Socioecological Challenges of Polio Supplementary Immunization Activities (SIAs) in the Asia-Pacific Region: A Systematic Review

Background

Polio supplementary immunization activities (SIAs) are one of the polio eradication pillars in the Global Polio Eradication Initiative (GPEI) that increased the immunization coverage and made progress towards polio eradication. However, socioecological challenges faced during SIAs contribute to suboptimal campaign quality. The aim of this review is to identify the reported challenges during polio supplementary immunization activities (SIAs) and associated improvement strategies based on the socioecological model (SEM).

Methods

Articles were searched from three databases which were WOS, Scopus, and PubMed. The systemic review identified the primary articles related to SIA that focused on the impact of immunization coverage, challenges, and improvement strategies. The inclusion criteria were open access English articles that were published between 2012 and 2021 and conducted in the Asia region.

Results

There are nine articles described and explained regarding some form of supplementary immunization activities (SIAs) in their findings across Asia region. The majority of studies selected reported on post vaccination coverage and revealed a multifaceted challenge faced during SIAs which are widely diverse range from the microlevel of interpersonal aspects up to the macrolevel of government policy. Upon further analysis, the intervention at community level was the most dominant strategies reported during the SIA program.

Conclusions

An effective SIAs program provides the opportunity to increase the national capacity of the polio immunization program, reducing inequities in service delivery and offering additional public health benefits in controlling polio outbreaks in both endemic and nonendemic countries. Strengthening routine immunization (RI) programmes is also important for the sustainability of SIA's programs. Despite the challenges and hurdles, many Asian countries exhibited great political willingness to boost polio immunization coverage through SIA efforts.

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.

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

The objective of this article is to analyse and quantify the side effects of the Polio Eradication Initiative on routine immunization performance in India. Past studies have faced methodological challenges in assessing these side effects. This article offers a methodological alternative for health policy analysts. The research uses secondary household survey data from the Indian District-Level Household and Facility Survey (DLHS), focusing on children aged 10-30 months in the Northern Indian states of Uttar Pradesh (n = 34 327) and Bihar (n = 20 525). Covering the years 2002-08, this is the latest large-scale data from India that enables the matching technique used in this article. District-level programme intensity data of the Polio Eradication Initiative in India were reconstructed using publicly available resources. The methodological innovation compared with previous studies consists of matching each child in the DLHS data set with a child-specific value of programme exposure depending on its district of residence, its birth date, and the date of the survey interview. Average and age-specific associations between polio programme exposure and children's full immunization status were assessed using logistic regression, controlling for other determinants of immunization. The regression results show that the link is negative in Uttar Pradesh and positive in Bihar. Age-specific analysis shows that the positive association diminishes for older children in Bihar and that a negative association emerges and becomes increasingly pronounced for older children in Uttar Pradesh. This indicates that heterogeneous results emerge across two neighbouring states with similar programme intensity and suggests that the catch-up of unvaccinated older children may be a channel through which negative effects accrue. The method described in this article, based on an analytical focus on individual-level programme exposure, can therefore help health policy implementers and evaluators to illuminate positive or negative interactions between a health intervention and a health system.

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.

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.

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.

Measles Elimination Activities in the Western Pacific Region: Experience from the Republic of Korea

We describe the global status of measles control and elimination, including surveillance and vaccination coverage data provided by the World Health Organization (WHO). Since 2000, two doses of measles vaccine (MCV2) became recommended globally and the achievement of high vaccination coverage has led to dramatic decrease in the measles incidence. Our finding indicates that, in the Western Pacific Region (WPR), substantial progress has been made to control measles transmission in some countries; however, the measles virus continues to circulate, causing outbreaks. The Republic of Korea (ROK) experienced a series of resurgence of measles due to the importation and healthcare-associated transmission in infants, however overall incidence and surveillance indicators met the WHO criteria for measles elimination. The ROK was verified to be measles-free along with Australia, Mongolia, and Macau, China in 2014. One of the effective elimination activities was the establishment of solid keep-up vaccination system in school settings. The lessons learnt from the measles elimination activities in Korea may contribute to enhancing the surveillance schemes and strengthening of vaccination programs in member countries and areas of WPR.

The impact of polio eradication on routine immunization and primary health care: a mixed-methods study

Background. After 2 decades of focused efforts to eradicate polio, the impact of eradication activities on health systems continues to be controversial. This study evaluated the impact of polio eradication activities on routine immunization (RI) and primary healthcare (PHC).

Methods. Quantitative analysis assessed the effects of polio eradication campaigns on RI and maternal healthcare coverage. A systematic qualitative analysis in 7 countries in South Asia and sub-Saharan Africa assessed impacts of polio eradication activities on key health system functions, using data from interviews, participant observation, and document review.

Results. Our quantitative analysis did not find compelling evidence of widespread and significant effects of polio eradication campaigns, either positive or negative, on measures of RI and maternal healthcare. Our qualitative analysis revealed context-specific positive impacts of polio eradication activities in many of our case studies, particularly disease surveillance and cold chain strengthening. These impacts were dependent on the initiative of policy makers. Negative impacts, including service interruption and public dissatisfaction, were observed primarily in districts with many campaigns per year.

Conclusions. Polio eradication activities can provide support for RI and PHC, but many opportunities to do so remain missed. Increased commitment to scaling up best practices could lead to significant positive impacts.

The effects and costs of expanding the coverage of immunisation services in developing countries: a systematic literature review

The range of potential effects and costs of interventions to expand the coverage of immunisation programs in developing countries was reviewed for the first time and demonstrated that increasing coverage is achievable. With the exception of a mass campaign, all interventions were reported to increase the proportion of fully vaccinated children. The findings are of particular value for policy debates about the introduction of new vaccines versus the need to vaccinate as many children as possible with the current ones. The review highlighted the need for: cost analyses to be undertaken alongside evaluations of interventions; and an improvement in the methodological quality of studies.

Global health goals: lessons from the worldwide effort to eradicate poliomyelitis

The Global Polio Eradication Initiative was launched in 1988. Assessment of the politics, production, financing, and economics of this international effort has suggested six lessons that might be pertinent to the pursuit of other global health goals. First, such goals should be based on technically sound strategies with proven operational feasibility in a large geographical area. Second, before launching an initiative, an informed collective decision must be negotiated and agreed in an appropriate international forum to keep to a minimum long-term risks in financing and implementation. Third, if substantial community engagement is envisaged, efficient deployment of sufficient resources at that level necessitates a defined, time-limited input by the community within a properly managed partnership. Fourth, although the so-called fair-share concept is arguably the best way to finance such goals, its limitations must be recognised early and alternative strategies developed for settings where it does not work. Fifth, international health goals must be designed and pursued within existing health systems if they are to secure and sustain broad support. Finally, countries, regions, or populations most likely to delay the achievement of a global health goal should be identified at the outset to ensure provision of sufficient resources and attention. The greatest threats to poliomyelitis eradication are a financing gap of US 210 million dollars and difficulties in strategy implementation in at most five countries.

Immunisation strategies for viral diseases in developing countries

In just under a quarter of a century, the Expanded Programme on Immunisation has been associated with an increase in infant immunisation coverage from around 5% to 80%, and the prevention of at least 3 million deaths annually, at very low cost. The global target of poliomyelitis eradication by the year 2000 appears feasible. Measles is the next likely target for eradication via immunisation, through 'catch-up', 'keep up' and 'follow-up' strategies which have proven highly effective in the Americas. Yet much needs to be done in order to extend readily achievable immunisation benefits equitably to all the world's people and to realise the potential of existing and soon to be available vaccines for disease control and eradication, as experience with yellow fever and hepatitis B vaccines demonstrates. Unsafe injection practices are widespread, have received inadequate attention, and cause a substantial global burden of blood-borne infections. The risk of increasing global inequity in immunisation highlights the centrality of resource allocation priorities in determining the extent to which the benefits of immunisation will be realised, particularly for new vaccines which are significantly more costly than established EPI vaccines. WHO/UNICEF strategies to target more effectively immunisation support to the neediest countries, to prioritise new vaccines, and to target carefully vaccine procurement and encourage sharply tiered vaccine pricing support both equity and sustainability. However, increasing the resources available to immunisation is vital and requires powerful advocacy on public health, moral, cost-effectiveness and legal grounds. More appropriate resource allocation priorities could readily provide the means necessary to address both technical and operational immunisation challenges.