Rotavirus vaccine product switch in Ghana: An assessment of service delivery costs, switching costs, and cost-effectiveness

Ghana introduced rotavirus vaccine (ROTARIX 1-dose presentation) into the routine national immunization program in 2012 and switched to a different product (ROTAVAC 5-dose presentation) in 2020. ROTAVAC has a lower price per dose (US$0.85 versus US$2.15 for ROTARIX) and smaller cold chain footprint but requires more doses per regimen (three versus two). This study estimates the supply chain and service delivery costs associated with each product, the costs involved in switching products, and compares the cost-effectiveness of both products over the next ten years. We estimated the supply chain and service delivery costs associated with ROTARIX and ROTAVAC (evaluating both the 5-dose and 10-dose presentations) using primary data collected from health facilities in six of the 14 regions in the country. We estimated the costs of switching from ROTARIX to ROTAVAC using information collected from key informant interviews and financial records provided by the government. All costs were reported in 2020 US$. We used the UNIVAC decision-support model to evaluate the cost-effectiveness (US$ per disability-adjusted life-year (DALY) averted from government and societal perspectives) of ROTARIX and ROTAVAC (5-dose or 10-dose presentations) compared to no vaccination, and to each other, over a ten-year period (2020 to 2029). We ran probabilistic sensitivity analyses and other threshold analyses. The supply chain and service delivery economic cost per dose was $2.40 for ROTARIX, $1.81 for ROTAVAC 5-dose, and $1.76 for ROTAVAC 10-dose. The financial and economic cost of switching from ROTARIX to ROTAVAC 5-dose was $453,070 and $883,626, respectively. Compared to no vaccination, the cost per DALY averted was $360 for ROTARIX, $298 for ROTAVAC 5-dose, and $273 for ROTAVAC 10-dose. ROTAVAC 10-dose was the most cost-effective option and would be cost-effective at willingness-to-pay thresholds exceeding 0.12 times the national GDP per capita ($2,206 in the year 2020). The switch from ROTARIX to ROTAVAC 5-dose in 2020 was cost-saving. Rotavirus vaccination is highly cost-effective in Ghana. A switch from ROTAVAC 5-dose to ROTAVAC 10-dose would be cost-saving and should be considered.

Community Barriers, Enablers, and Normative Embedding of Second Year of Life Vaccination in Ghana: A Qualitative Study

INTRODUCTION

Coverage rates for second year of life (2YL) vaccination still lag behind infant vaccination in most settings. We conducted a qualitative baseline study of community barriers and enablers to acceptance of 2YL vaccines in Ghana 4 years after introducing the second dose of the measles-containing vaccine.

METHODS

We conducted 26 focus group discussions in 2016 with men and women caregivers from mixed urban, peri-urban, and rural areas, as well as pastoralists, using semistructured topic guides based on the Health Belief Model theory. We conducted a thematic analysis of the discussion using NVivo software. We use Normalization Process Theory to contextualize results as a snapshot of a dynamic process of community adaptation to change to a well-established routine immunization schedule following 2YL introduction.

RESULTS

Routine immunization for infants enjoys resilient demand, grounded in strong community norms despite surprisingly low levels of vaccine literacy. Despite best practices like integration with the established 18-month "weighing visit," demand for 2YL vaccination is still conditional on individual awareness and competition for limited maternal time, household resources, and other health concerns. An embedded norm that children should be fully vaccinated by 12 months originally sustained Expanded Programme for Immunization goals but now discouraged some caregivers from seeking vaccines for children perceived to be "too old" to vaccinate. Caregivers cited greater costs and inconvenience of taking older, heavier children in for vaccination and anticipated criticism from both community members and health care providers for coming "too late."

CONCLUSION

Closing the 2YL vaccination coverage gap will ultimately require modifying embedded norms among caregivers and health care providers alike. Time is necessary but not sufficient to reach this goal. Progress can be accelerated by increasing the level of community and institutional engagement and adapting services where possible to minimize added costs to caregivers of vaccinating older children.

Vaccine wastage in Ghana, Mozambique, and Pakistan: An assessment of wastage rates for four vaccines and the context, causes, drivers, and knowledge, attitudes and practices for vaccine wastage

Vaccine procurement costs comprise a significant share of immunization program costs in low- and middle-income countries, yet not all procured vaccines are administered. Vaccine wastage occurs due to vial breakage, excessive heat or freezing, expiration, or when not all doses in a multidose vial are used. Better estimates of vaccine wastage rates and their causes could support improved management of vaccine stocks and reduce procurement costs. This study examined aspects of wastage for four vaccines at service delivery points in Ghana (n = 48), Mozambique (n = 36), and Pakistan (n = 46). We used prospective data from daily and monthly vaccine usage data entry forms, along with cross-sectional surveys, and in-depth interviews. The analysis found that estimated monthly proportional open-vial wastage rates for vaccines in single-dose vials (SDV) or in multi-dose vials (MDV) that can be kept refrigerated up to four weeks after opening ranged from 0.08 % to 3 %. For MDV where remaining doses are discarded within six hours after opening, the mean wastage rates ranged from 5 % to 33 %, with rates being highest for measles containing vaccine. Despite national-level guidance to open a vaccine vial even when only one child is present, vaccines in MDV that are discarded within six hours of opening are sometimes offered less frequently than vaccines in SDV or in MDV where remaining doses can be used for up to 4 weeks. This practice can lead to missed opportunities for vaccination. While closed-vial wastage at service delivery points (SDPs) was relatively rare, individual instances can result in large losses, suggesting that monitoring closed-vial wastage should not be neglected. Health workers reported insufficient knowledge of vaccine wastage tracking and reporting methods. Improving reporting forms would facilitate more accurate reporting of all causes of wastage, as would additional training and supportive supervision. Globally, decreasing doses per vial could reduce open-vial wastage.

Evaluation of Container Clinics as an Urban Immunization Strategy: Findings from the First Year of Implementation in Ghana, 2017-2018

BACKGROUND

In 2017, the Expanded Programme on Immunization in Ghana opened two container clinics in Accra, which were cargo containers outfitted to deliver immunizations. At each clinic, we assessed performance and clinic acceptance during the first 12 months of implementation.

METHODS

We employed a descriptive mixed-method design using monthly administrative immunization data, exit interviews with caregivers of children of <5 years (N = 107), focus group discussions (FGDs) with caregivers (n = 6 FGDs) and nurses (n = 2 FGDs), and in-depth interviews (IDIs) with community leaders (n = 3) and health authorities (n = 3).

RESULTS

Monthly administrative data showed that administered vaccine doses increased from 94 during the opening month to 376 in the 12th month across both clinics. Each clinic exceeded its target doses for the 12-23 month population (second dose of measles). Almost all (98%) exit interview participants stated that the clinics made it easier to receive child health services compared to previous health service interactions. The accessibility and acceptability of the container clinics were also supported from health worker and community perspectives.

CONCLUSIONS

Our initial data support container clinics as an acceptable strategy for delivering immunization services in urban populations, at least in the short term. They can be rapidly deployed and designed to serve working mothers in strategic areas.

Post introduction evaluation of the malaria vaccine implementation programme in Ghana, 2021

BACKGROUND

Malaria remains a public health challenge in Sub-Saharan Africa with the region contributing to more than 90% of global cases in 2020. In Ghana, the malaria vaccine was piloted to assess the feasibility, safety, and its impact in the context of routine use alongside the existing recommended malaria control measures. To obtain context-specific evidence that could inform future strategies of introducing new vaccines, a standardized post-introduction evaluation (PIE) of the successes and challenges of the malaria vaccine implementation programme (MVIP) was conducted.

METHODS

From September to December 2021, the WHO Post-Introduction Evaluation (PIE) tool was used to conduct a mixed methods evaluation of the MVIP in Ghana. To ensure representativeness, study sites and participants from the national level, 18 vaccinating districts, and 54 facilities from six of the seven pilot regions were purposively selected. Quantitative and qualitative data were collected using data collection tools that were adapted based on the WHO PIE protocol. We performed summary descriptive statistics on quantitative data, thematic analysis on qualitative data, and triangulation of the results from both sets of analyses.

RESULTS

About 90.7% (49/54) of health workers stated that the vaccine introduction process was smooth and contributed to an overall improvement of routine immunisation services. About 87.5% (47/54) of healthcare workers, and 95.8% (90/94) of caregivers accepted RTS,S malaria vaccine. Less than half [46.3%; (25/54)] of the healthcare workers participated in the pre-vaccine introduction training but almost all [94.4%; (51/54)] were able to constitute and administer the vaccine appropriately. About 92.5% (87/94) of caregivers were aware of the RTS,S introduction but only 44.0% (44/94) knew the number of doses needed for maximum protection. Health workers believed that the MVIP has had a positive impact on under five malaria morbidity.

CONCLUSIONS

The malaria vaccine has been piloted successfully in Ghana. Intensive advocacy; community engagement, and social mobilization; and regular onsite supportive supervision are critical enablers for successful introduction of new vaccines. Stakeholders are convinced of the feasibility of a nationwide scale up using a phased subnational approach taking into consideration malaria epidemiology and global availability of vaccines.

Building and sustaining public and political commitment to the value of vaccination: Recommendations for the Immunization Agenda 2030 (Strategic Priority Area 2)

Vaccines have contributed to substantial improvements in health and social development outcomes for millions in recent decades. However, equitable access to immunization remains a critical challenge that has stalled progress toward improving several health indicators around the world. The COVID-19 pandemic has also negatively impacted routine immunization services around the world further threatening universal access to the benefits of lifesaving vaccines. To overcome these challenges, the Immunization Agenda 2030 (IA2030) focuses on increasing both commitment and demand for vaccines. There are three broad barriers that will need to be addressed in order to achieve national and subnational immunization targets: (1) shifting leadership priorities and resource constraints, (2) visibility of disease burden, and (3) social and behavioral drivers. IA2030 proposes a set of interventions to address these barriers. First, efforts to ensure government engagement on immunization financing, regulatory, and legislative frameworks. Next, those in subnational leadership positions and local community members need to be further engaged to ensure local commitment and demand. Governance structures and health agencies must accept responsibility and be held accountable for delivering inclusive, quality, and accessible services and for achieving national targets. Further, the availability of quality immunization services and commitment to adequate financing and resourcing must go hand-in-hand with public health programs to increase access to and demand for vaccination. Last, strengthening trust in immunization systems and improving individual and program resilience can help mitigate the risk of vaccine confidence crises. These interventions together can help ensure a world where everyone, everywhere has access to and uses vaccines for lifesaving vaccination.

Evaluation of the Impact of Immunization Second Year of Life Training Interventions on Health Care Workers in Ghana

Applying performance-based training interventions that follow adult learning principles and include follow-up activities after training may help to solve specific performance problems and improve health care workers’ performance in immunization service delivery. These strategies facilitate learning, minimize the forgetting curve for health care workers, and should be considered as a standard practice for future training interventions.

Introduction:

As part of a suite of training interventions to improve the knowledge and practice of immunization in the second year of life (2YL), training of trainers workshops were conducted with regional and district health management teams (DHMTs) in 15 districts in 3 regions of Ghana. Using adult learning principles, DHMTs implemented several capacity-building activities at the subdistrict and health facility levels, including health facility visits, on-the-job training, and review meetings. The current evaluation investigated whether frontline health care workers (HCWs) reported or demonstrated improvements in knowledge, attitudes, and practices after training interventions.

Methods:

Quantitative and qualitative methods with a utilization-focused approach guided the framework for this evaluation. A systematic random sample of 115 HCWs in 3 regions of Ghana was selected to complete a competency survey before and after training, which focused on 3 core competency areas—Expanded Programme on Immunization (EPI) policy; communication with caregivers; and immunization data management, recording, and use. Interviews and direct observations by data collectors were done to assess HCWs’ knowledge, self-reported attitude, and behavior changes in practices.

Results:

Of 115 HCWs, 102 were surveyed before and 4 months after receiving capacity-building interventions. Modest but not statistically significant improvements were found in knowledge on EPI policy, immunization data management, and communication skills with caregivers. HCWs reported that they had improved several attitudes and practices after the 2YL training. The most improved practice reported by HCWs and observed in all 3 regions was the creation of a defaulter list.

Discussion:

Findings of this evaluation provide encouraging evidence in taking the first step toward improving HCW knowledge, attitudes, and practices for 3 core immunization competency areas. The use of learner-focused teaching methods combined with adult learning principles is helpful in solving specific performance problems (such as lack of knowledge of EPI policy).

Applying Adult Learning Best Practices to Design Immunization Training for Health Care Workers in Ghana

INTRODUCTION

A 2016 assessment of frontline health care workers (HCWs) in Ghana identified knowledge, skill, and attitude gaps related to immunization during the second year of life (2YL). The U.S. Centers for Disease Control and Prevention subsequently supported the Ghana Health Service Immunization Program to apply best practices of adult learning and training of trainers (TOT) for a cascade training program for 2YL.

METHODS

Five districts from each of the 3 regions (Greater Accra, Northern, and Volta) were selected for the TOT based on key measles and rubella vaccination coverage indicators. The design incorporated best practices of adult learning and TOT. The curriculum integrated 3 major topical themes: technical (immunization topics), operational, and training adults. The technical and operational content was based on HCW tasks most directly affecting 2YL objectives. A cross-functional team developed all classroom, field activity, and training evaluation materials.

RESULTS

Seventy-four participants attended TOT workshops in 2017. Based on a rubric defined by the course designers, 99% of the participants reported an acceptable level of confidence to apply and teach the course content. After the TOTs, participants conducted 65 workshops, 43 field visits, and 4 review meetings, reaching 1,378 HCWs within 7 months. Fifty-four percent of HCWs who received training from TOT participants reported an acceptable level of confidence in using the skills, and 92% reported they would prioritize applying the skills acquired during the training.

DISCUSSION

The success factors for effective adult learning and TOT can be applied to design and implement high-quality TOT even in resource-limited settings. The factors include using a variety of approaches, spending enough class time to prepare TOT participants for their training role, setting specific expectations for cascading the training, and following up through mentorship and reporting. Strong collaboration across the administrative levels of the Ghana Health Service enabled cascade training.

An 11-year trend of rubella incidence cases reported in the measles case-based surveillance system, Ghana

Introduction

rubella is vaccine-preventable and vaccination is the most cost-effective approach to control the disease and avoid the management of congenital rubella syndrome cases. Ghana introduced the rubella vaccine into the routine immunization program in 2013. Since then there have not been any evaluation of the epidemiology of rubella. We determined the disease trends and the population demographics of rubella cases, in the Ghana national measles case-based surveillance system.

Methods

we reviewed the measles case-based surveillance data from 2007 to 2017. Descriptive data statistics was done and expressed as frequencies and proportions. Chi-square test was used to establish associations.

Results

a total of 11,483 suspected cases for measles received and tested for measles IgM antibodies and 1,137(12.98%) confirmed positive for the period. Of these 10,077 were negative and 250 indeterminate for measles and tested for rubella and 2,090 (20.23%) confirmed positive for rubella IgM antibodies. More females (21.45%) were affected than males (19.48%). Majority of the confirmed positives were recorded in the urban areas. Children aged 15 years or less were mostly affected. There was a statistical difference between incidence cases and sex (χ2=6.03, p-value = 0.014), or age (χ2=283.56, p-value < 0.001) or area (χ2= 6.17, p-value = 0.013). Most infections occurred during the dry season.

Conclusion

children less than 15 years were mostly affected with majority being females. The highest incidence of cases was before the rains and occurred mostly in urban areas. The incidence of cases has declined significantly with the introduction of the rubella vaccine.

Costs of continuing RTS,S/ASO1E malaria vaccination in the three malaria vaccine pilot implementation countries

Background

The RTS,S/ASO1_E malaria vaccine is being piloted in three countries—Ghana, Kenya, and Malawi—as part of a coordinated evaluation led by the World Health Organization, with support from global partners. This study estimates the costs of continuing malaria vaccination upon completion of the pilot evaluation to inform decision-making and planning around potential further use of the vaccine in pilot areas.

Methods

We used an activity-based costing approach to estimate the incremental costs of continuing to deliver four doses of RTS,S/ASO1_E through the existing Expanded Program on Immunization platform, from each government’s perspective. The RTS,S/ASO1_E pilot introduction plans were reviewed and adapted to identify activities for costing. Key informant interviews with representatives from Ministries of Health (MOH) were conducted to inform the activities, resource requirements, and assumptions that, in turn, inform the analysis. Both financial and economic costs per dose, cost of delivery per dose, and cost per fully vaccinated child (FVC) are estimated and reported in 2017 USD units.

Results

At a vaccine price of $5 per dose and assuming the vaccine is donor-funded, our estimated incremental financial costs range from $1.70 (Kenya) to $2.44 (Malawi) per dose, $0.23 (Malawi) to $0.71 (Kenya) per dose delivered (excluding procurement add-on costs), and $11.50 (Ghana) to $13.69 (Malawi) per FVC. Estimates of economic costs per dose are between three and five times higher than financial costs. Variations in activities used for costing, procurement add-on costs, unit costs of per diems, and allowances contributed to differences in cost estimates across countries.

Conclusion

Cost estimates in this analysis are meant to inform country decision-makers as they face the question of whether to continue malaria vaccination, should the intervention receive a positive recommendation for broader use. Additionally, important cost drivers for vaccine delivery are highlighted, some of which might be influenced by global and country-specific financing and existing procurement mechanisms. This analysis also adds to the evidence available on vaccine delivery costs for products delivered outside the standard immunization schedule.

The Costs of Implementing Vaccination With the RTS,S Malaria Vaccine in Five Sub-Saharan African Countries

Background. The World Health Organization has recommended pilot implementation of a candidate vaccine against malaria (RTS,S/AS01) in selected sub-Saharan African countries. This exploratory study aimed to estimate the costs of implementing RTS,S in Burkina Faso, Ghana, Kenya, Mozambique, and Tanzania. Methods. Key informants of the expanded program on immunization at all levels in each country were interviewed on the resources required for implementing RTS,S for routine vaccination. Unit prices were derived from the same sources or from international price lists. Incremental costs in 2015 US dollars were aggregated per fully vaccinated child (FVC). It was assumed the four vaccine doses were either all delivered at health facilities or the fourth dose was delivered in an outreach setting. Results. The costs per FVC ranged from US$25 (Burkina Faso) to US$37 (Kenya) assuming a vaccine price of US$5 per dose. Across countries, recurrent costs represented the largest share dominated by vaccines (including wastage) and supply costs. Non-recurrent costs varied substantially across countries, mainly because of differences in needs for hiring personnel, in wages, in cold-room space, and equipment. Recent vaccine introductions in the countries may have had an impact on resource availability for a new vaccine implementation. Delivering the fourth dose in outreach settings raised the costs, mostly fuel, per FVC by less than US$1 regardless of the country. Conclusions. This study provides relevant information for donors and decision makers about the cost of implementing RTS,S. Variations within and across countries are important and the unknown future price per dose and wastage rate for this candidate vaccine adds substantially to the uncertainty about the actual costs of implementation.

Pre- and in-service training of health care workers on immunization data management in LMICs: a scoping review

BACKGROUND

Healthcare providers (HCPs) are recognized as one of the cornerstones and drivers of health interventions. Roles such as documentation of patient care, data management, analysing, interpreting and appropriate use of data are key to ending vaccine-preventable diseases (VPDs). However, there is a great deal of uncertainty and concerns about HCPs' skills and competencies regarding immunization data handling and the importance of data use for improving service delivery in low- and middle-income countries (LMICs). Questions about the suitability and relevance of the contents of training curriculum, appropriateness of platforms through which training is delivered and the impact of such training on immunization data handling competencies and service delivery remain a source of concern. This review identified and assessed published studies that report on pre- and in-service training with a focus on HCPs' competencies and skills to manage immunization data in LMICs.

METHODS

An electronic search of six online databases was performed, in addition to websites of the WHO, Global Alliance for Vaccines and Immunization (GAVI), Oxfam International, Save the Children, Community Health Workers Central (CHW Central), UNAIDS and UNICEF. Using appropriate keywords, MeSH terms and selection procedure, 12 articles published between January 1980 and May 2019 on pre- and in-service training of HCPs, interventions geared towards standardized data collection procedures, data documentation and management of immunization data in LMICs, including curriculum reviews, were considered for analysis.

RESULTS

Of the 2705 identified references, only 12 studies met the inclusion criteria. The review provides evidence that shows that combined and multifaceted training interventions could help improve HCPs' knowledge, skills and competency on immunization data management. It further suggests that offering the right training to HCPs and sustaining standard immunization data management is hampered in LMICs by limited or/lack of training resources.

CONCLUSION

Pre-service training is fundamental in the skills' acquisition of HCPs; however, they require additional in-service training and supportive supervision to function effectively in managing immunization data tasks. Continuous capacity development in immunization data-management competencies such as data collection, analysis, interpretation, synthesis and data use should be strengthened at all levels of the health system. Furthermore, there is a need for periodic review of the immunization-training curriculum in health training institutions, capacity development and retraining tutors on the current trends in immunization data management.

Development of a valid and reliable scale to assess parents' beliefs and attitudes about childhood vaccines and their association with vaccination uptake and delay in Ghana

BACKGROUND

Parents' attitudes and beliefs in vaccination are important to understand for shaping vaccine acceptance and demand interventions. Little research has focused on developing a validated scale to measure parents' attitudes towards vaccinations in low and middle-income countries; Ghana provided an opportunity develop a caregiver vaccination attitudes scale (CVAS) validated against childhood vaccine compliance.

METHODS

We conducted a cluster survey of 373 households with children aged 12-35 months of age from Northern Region, Ghana. Caregivers responded to 22 vaccination behavior and belief survey items and provided the child's vaccination status. In exploratory factor analysis (EFA) to assess CVAS content validity, we used parallel analysis to guide the number of factors to extract and principal axis factor analysis for factor extraction. Reliability of the scale was assessed using McDonald's Omega coefficient. Criterion validity of scale and subscales was assessed against receipt of vaccinations by 12 months of age and vaccination delay, using number of days undervaccinated.

RESULTS

EFA of CVAS responses resulted in removing 11 of 22 survey items due to loadings <0.30 and development of a 5-factor structure with subscales for Vaccine-Preventable Disease (VPD) Awareness, Vaccine Benefits, Past Behavior, Vaccine Efficacy and Safety, and Trust. The 5 factors accounted for 69% of the common variance and omega coefficients were >0.73 for all subscales. Validity analysis indicated that for every unit increase in the parent's scale score, the odds of the child being vaccinated decreased by 0.58 (95% confidence interval [CI]: 0.37, 0.68) and the number of days under-vaccinated increased by 86 (95%CI: 28, 143). The final 3-factor scale included Vaccine Benefits, Past Behavior, and Vaccine Efficacy and Safety.

DISCUSSION

The final CVAS included three factors associated with vaccine compliance in Ghana, although several survey items suggested for use in vaccine acceptance scales were dropped. Replicating this study in several country settings will provide additional evidence to assist in refining a tool for use in routine vaccine acceptance and demand surveillance efforts.

Community-based mass treatment with azithromycin for the elimination of yaws in Ghana-Results of a pilot study

INTRODUCTION

The WHO yaws eradication strategy consists of one round of total community treatment (TCT) of single-dose azithromycin with coverage of > 90%.The efficacy of the strategy to reduce the levels on infection has been demonstrated previously in isolated island communities in the Pacific region. We aimed to determine the efficacy of a single round of TCT with azithromycin to achieve a decrease in yaws prevalence in communities that are endemic for yaws and surrounded by other yaws-endemic areas.

METHODS

Surveys for yaws seroprevalence and prevalence of skin lesions were conducted among schoolchildren aged 5-15 years before and one year after the TCT intervention in the Abamkrom sub-district of Ghana. We used a cluster design with the schools as the primary sampling unit. Among 20 eligible primary schools in the sub district, 10 were assigned to the baseline survey and 10 to the post-TCT survey. The field teams conducted a physical examination for skin lesions and a dual point-of-care immunoassay for non-treponemal and treponemal antibodies of all children present at the time of the visit. We also undertook surveys with non-probabilistic sampling to collect lesion swabs for etiology and macrolide resistance assessment.

RESULTS

At baseline 14,548 (89%) of 16,287 population in the sub-district received treatment during TCT. Following one round of TCT, the prevalence of dual seropositivity among all children decreased from 10.9% (103/943) pre-TCT to 2.2% (27/1211) post-TCT (OR 0.19; 95%CI 0.09-0.37). The prevalence of serologically confirmed skin lesions consistent with active yaws was reduced from 5.7% (54/943) pre-TCT to 0.6% (7/1211) post-TCT (OR 0.10; 95% CI 0.25-0.35). No evidence of resistance to macrolides against Treponema pallidum subsp. pertenue was seen.

DISCUSSION

A single round of high coverage TCT with azithromycin in a yaws affected sub-district adjoining other endemic areas is effective in reducing the prevalence of seropositive children and the prevalence of early skin lesions consistent with yaws one year following the intervention. These results suggest that national yaws eradication programmes may plan the gradual expansion of mass treatment interventions without high short-term risk of reintroduction of infection from contiguous untreated endemic areas.

Immunization delivery in the second year of life in Ghana: the need for a multi-faceted approach

Introduction

in 2012, pneumococcal conjugate vaccine (PCV), rotavirus vaccine and a second dose of measles-containing vaccine (MCV2) were introduced into the Expanded Program on Immunization (EPI) in Ghana. According to Ghana’s EPI schedule, PCV and rotavirus vaccine are given in the first year of life and MCV2 in the second year of life (2YL) at 18 months. Although coverage with the last doses of PCV and rotavirus vaccine reached almost 90% coverage within four years of introduction, MCV2 coverage did not rise above 70%. The World Health Organization Global Measles and Rubella Strategic Plan established a 2020 milestone to achieve at least 95% coverage with the first and second doses of measles-containing vaccine in each district and nationally. We developed a project to address challenges to delivery of immunizations and other child health services at the 18-month visit and throughout the 2YL.

Methods

from March to April 2016, we conducted a cluster survey of households (HHs) with children 24-35 months of age in three regions in Ghana to assess knowledge, attitudes and beliefs among caregivers about immunization during the 2YL and to collect childhood vaccination history data using vaccination cards. Three independent samples were selected from the Northern (NR), Volta (VR), and Greater Accra (GAR) regions. A survey and direct observations were performed a ta representative sample of health facilities (HFs) providing immunization services in the same regions to further characterize barriers to immunization access, utilization and delivery in the 2YL.

Results

data on a total of 464 children ages 24-35 months were collected in the HH survey: 211 in NR, 153 in VR, and 100 in GAR (response rate > 99%). First dose of measles-containing vaccine (MCV1) coverage was (NR: 87%, VR: 96%, GAR: 99%); however, MCV2 coverage was lower (NR: 60%, VR: 83%, GAR: 70%). MCV1 to MCV2 dropout was 32% in NR, 14% in VR, and 31% in GAR. Caregiver awareness of immunization against measles was 69% in NR, 75% in VR, and 68% in GAR yet less than half knew the recommended ages for receiving the vaccine, (NR: 4%, VR: 9%, GAR: 44%). Among 160 HFs participating in the survey (>50 in each region), most lacked a defaulter tracing system (NR: 94%,VR: 76%,GAR: 85%). A varying proportion of HCWs correctly indicated how to record a catch-up first dose of MCV administered to an 18-month-old child in the 12-23 month immunization register (NR: 38%, VR: 55%, GAR: 67%) and on the vaccination card (NR: 54%, VR: 53%, GAR: 76%). Although more than half of caregivers would accept text messages, (NR: 57%, VR: 78%, GAR: 96%) including reminders, related to their child’s immunizations, < 10% HFs were utilizing this practice.

Conclusion

challenges encountered with the establishment of an immunization visit beyond the first year of life included knowledge gaps among caregivers, high dropout rates between MCV1 and MCV2 in all study regions, and a lack of defaulter tracing systems in most healthcare facilities providing childhood immunizations. Targeted strategies that promote behavioral, cultural, and policy changes are needed to strengthen 2YL child health service delivery and improve vaccination coverage.

Regional disparities in immunization services in Ghana through a bottleneck analysis approach: implications for sustaining national gains in immunization

Background

Immunization is considered one of the most cost effective public health interventions for reducing child morbidity, mortality and disability. The aim of this work is to describe the application of the Bottleneck analysis (BNA) process to assess gaps in immunization services in Ghana and implications for sustaining the gains in Immunization coverage.

Methods

A national assessment was conducted in May 2015, through use of desk reviews, field visits and key informant interviews. Quantitative data were analysed with the BNA Tool (an excel-based tool) based directly on service coverage data and programme monitoring and review reports in Ghana. Outputs were generated based on service coverage indicators; supply side/health system factors (commodities, human resource and access), demand side (service utilisation) and quality/effective coverage. National targets were used as benchmarks to assess gaps in coverage indicators.

Results

In all, only 50% of regions and districts had health facilities with at least 80% of health care workers training provided in-service training on routine immunization; only 40% of district had communities with functional fixed or outreach EPI service delivery point and over 70% of regions and districts had challenges with effective coverage of infants aged 0-11 months fully immunized during the past year.

Other key health system bottlenecks included, limited number of fixed and outreach sites, difficult to reach island communities along the Volta Basin, inadequate storage facilities for vaccines at lower levels, stock out of vaccines and auto destruct syringes and absence of updated policies/field guides at services delivery points/facilities. In addition, inadequate in-service training in routine Immunization and absence of good quality data were major challenges. Demand side bottlenecks included fear of mothers on the safety of multiple vaccines and limited active involvement of communities in Immunization service delivery.

Conclusion

The BNA tool and approach provided data driven planning of health service in Ghana. This resulted in the development of regional and national operational plans for immunization and will be the baseline for evaluating the national programme in three years.

Sex differences in perceived risk and testing experience of HIV in an urban fishing setting in Ghana

Introduction

Understanding sex differences in willingness to test and testing experience could aid the design of focus interventions to enhance uptake and engagement with care, treatment and support services. This study determined differences in perceived risk of acquiring HIV, willingness to test and HIV testing experience in an urban fishing community.

Methods

A cross-sectional community survey was conducted in 2013 among men and women in two fishing communities (Chorkor and James Town) in Accra. In all, 554 subjects (≥18 years) were involved, 264 in Chorkor and 290 in James Town. Data on demographic characteristics, perceived risk for HIV and willingness to test for HIV and testing experience were collected with a structured questionnaire. Descriptive statistics and Chi square test were used for the analysis at 95% significant level, using SPSS version 21.

Results

Of 554 subjects, 329 (59.4%) were females, and median age was 32 years. Overall, only 91(40.4%) men and 118(35.9%) women perceived themselves to be at risk of acquiring HIV. A significant proportion of women were willing to test for HIV compared to men (86.3% vs. 80.0%, P = 0.048). Women were more likely to have ever tested for HIV compared to men (42.2% vs. 28.6%, P = 0.001) and more women had tested within 12 months prior to survey than men (49.6% vs. 40.6%, P = 0.230). Of the number who had tested for HIV infection, a higher proportion of men tested voluntarily 42(65.6%), while a higher proportion of women tested as part of healthcare service received 96(69.1%); (P = 0.001; indicating women vs. men).

Conclusion

Sex differences in risk perception and willingness to test need more focused public education and behaviour change communication strategies to achieve high coverage. Community-based strategies could improve HIV testing among men whilst more access to testing in health settings should be available to women in these communities.

The prevalence and risk factors for hepatitis B surface ag positivity in pregnant women in eastern region of ghana

BACKGROUND/AIMS

The aim of this study was to evaluate the prevalence and risk factors for hepatitis B surface antigen (HBsAg) positivity in pregnant Ghanaian women.

METHODS

We surveyed 1,500 pregnant women in Eastern region of Ghana. Direct interviews were performed by trained nurses using standardized questionnaires. Pregnant women were screened for human immunodeficiency virus (HIV) and hepatitis B infections, hemoglobin levels and sickle cell anemia as part of the antenatal check-up.

RESULTS

The overall HBsAg positive rate was 10.6%, which varied among districts (13.8% for Kwahu West, 12.4% for Upper Manya, and 2.2% for Yilo Krobo). HBsAg positivity was significantly higher in women with depression (odds ratio [OR], 3.74; 95% confidence interval [CI], 2.13 to 6.57) and HIV (OR, 2.03; 95% CI, 1.06 to 3.89). Age, education, and gravidity were not related to HBsAg positivity. Anti-hepatitis B immunoglobulin for newborns of HBsAg-positive mothers is not provided at birth in public health facilities in Ghana. However, hepatitis B vaccination is provided as part of a routine vaccination schedule starting at 6 weeks of age.

CONCLUSIONS

To prevent mother-to-child transmission of hepatitis B, screening tests for HBsAg in pregnant women and hepatitis B vaccination of newborns immediately after birth need to be performed in this region.

Sulphadoxine/pyrimethamine: an appropriate first-line alternative for the treatment of uncomplicated falciparum malaria in Ghanaian children under 5 years of age

OBJECTIVE

To assess whether chloroquine (CQ) still is an appropriate first-line drug for the treatment of uncomplicated falciparum malaria in Ghana and whether sulphadoxine/pyrimethamine (SP) could be a good alternative.

METHOD

The parasitological, clinical and haematological responses to CQ and SP were studied in children < 5 years of age according to a modified WHO 28-day in vivo protocol. A total of 142 children attending the outpatients department meeting the inclusion criteria were randomly assigned to the CQ (n=72) or SP (n=70) group.

RESULTS

In the CQ group, 15 children (20.8%) exhibited early clinical failure (within 3 days) compared with only 1 (1.4%) in the SP group (P < 0.01). The clinical failure rate before day 14 (early treatment failure plus late treatment failure before day 14) also showed a marked advantage in favour of the SP group (1.4 against 29.2%). The median time to clinical failure was 11.5 days in the CQ group and 26 days in the SP group (P < 0.01). Of the 72 children treated with CQ, 9 (12.5%) had RIII resistance and 19 (26.4%) had RII resistance. A total of 36 (50.0%) were sensitive to CQ. From the 70 children treated with SP, none had RIII or RII resistance. There was no difference in haematological response between the two treatment groups.

CONCLUSION

Although there is little concordance on when to change treatment policy, the high resistance to CQ in this study supports the change to another first-line drug for children under 5 years of age. SP seems to be a good alternative, although a high RII and RIII resistance against this drug has already been reported in the coastal zones of Ghana.