CLOSING MR IMMUNITY GAPS EXPERIENCES FROM THE REGIONS MALAWI Geoffrey Zimkambani Chirwa EPI Manager
Outline (1) Background of the NIP and epidemiology of MR How did you diagnose that older teenager/adult susceptibility is (was) an issue in your country? (e.g. surveillance, serosurvey, outbreaks, admin coverage) How did you design a specific approach or strategy for closing immunity gaps, if any? (describe main facilitators and barriers for action)
Outline (2) Describe the approach and challenges in terms of: o o o o o o Political commitment Strategies Advocacy tools Financing Oversight Sustainability How did you measure success of the approach or strategy? (describe evaluations done or planned) Based on your experience, what monitoring and vaccination strategies would you use in the future, if the problem continues or returns?
Background of the National Immunization Programme The Malawi Expanded Programme on Immunization was established in 1979. Ten years after the establishment, the country attained the universal immunization goal when coverage was 80% for all childhood antigens. The high immunization coverage has been sustained for the past years, except when there was a global vaccine shortage and when there was a change in the recommended statistical proportion of children under 1 in 2000 & 2002 respectively. 4
National Immunization Coverage 2002-2015 5
Epidemiology of MR Malawi experienced a peak of suspected measles cases in 1997 with 10,845. In Malawi, measles used to be a major childhood public health problem until 1998 when the first catch up campaign was conducted. After the 1998 measles catch up campaign the suspected cases were reduced from 10,845 in 1997 to 3,501 in 1998.This campaign targeted the 15 years with national coverage of 95%. 6
Epidemiology of MR The impact of the campaign was a huge reduction in the number of suspected measles cases. This resulted in closure of the measles wards. Follow up campaigns were done in 2002, 2005 and 2008 targeting 5 years. In these follow up campaigns, a coverage of 95% was attained. Malawi experienced a huge measles outbreak in 2010 with 118,712 cases out of which 464 were lab confirmed for measles and 28 lab confirmed for rubella. A total of 249 deaths were reported representing a case fatality rate (CFR) of 0.21%. Out of 28 districts, Lilongwe reported the highest number of cases (24,455) and deaths (43). 7
Epidemiology of MR A second catch up Integrated measles campaign was conducted in 2010 targeting 15 years and a coverage of 95% was achieved. Cases dropped from 118,712 in 2010 to 766 in 2011 out of which 26 cases were lab confirmed for measles and 267 cases were lab confirmed for rubella. A follow up Integrated SIA was conducted in 2013 targeting 5 years and a coverage of 95% was achieved. 8
Measles Case Based Surveillance Malawi introduced Measles Case Based Surveillance in 1999 after a successful national measles catch up campaign in 1998. Only measles Igm was tested at the time of inception. Kamuzu Central Hospital Laboratory was designated as the National Measles Lab following the introduction of the Measles Case Based Surveillance. The programme started testing for rubella Igm in 2001 using the Measles Case Based Surveillance. Table 1a and b show suspected and confirmed cases for measles and rubella from 1997 to 2015. 9
Table 1a: Suspected and Confirmed Cases for Measles and Rubella 1997-2015 Year Total Suspected Cases Lab Confirmed Measles Cases Lab Confirmed Rubella Cases 1997 10,845 - - 1998 3,501 - - 1999 152 1-2000 304 0-2001 150 4 15 2002 92 2003 167 1 6 2004 1141 90 51 2005 184 24 51 10
Table 1b: Suspected and Confirmed Cases for Measles and Rubella 1997-2015 Year Total Suspected Cases Lab Confirmed Measles Cases Lab Confirmed Rubella Cases 2006 51 1 0 2007 143 19 23 2008 312 20 103 2009 630 21 53 2010 118,712 464 28 2011 766 26 267 2012 342 12 56 2013 299 1 23 2014 1307 3 433 2015 343 0 98 11
Trend of Suspected Measles Cases, Malawi- 1997 to 2015 Measles Measles Outbreak Catch up campaign Measles Outbreak Catch-up campaign Follow-up campaign Outbreak Follow-up campaign Follow-up campaign Follow-up campaign 12
Lab Confirmed Cases of Measles and Rubella 2003-2015 Catch up Measles Outbreak Follow-up campaign Measles Outbreak campaign Follow-up campaign Follow-up campaign 13
Diagnosing Susceptibility in Older Teenager/Adult (1) How did you diagnose that older teenager/adult susceptibility is (was) an issue in your country? (e.g. surveillance, serosurvey, outbreaks, admin coverage) 14
Diagnosing Susceptibility in Older Teenager/Adult (2) Use of Measles Case Based surveillance. Malawi has largely depend on surveillance for measles cases regardless of age. The surveillance case definition has no age limit. Surveillance data for both measles and rubella are analyzed regularly to observe the trend in each age group such as <5, 5-9, 10-14, or >15 years. Attack rates are then calculated. 15
Diagnosing Susceptibility in Older Use of the Measles Risk Analysis Tool The tool helps to determine susceptible. The tool uses birth cohort, immunization coverage, SIA coverage and sero-conversion over a period of time. Determination of outbreak risk threshold is done Use of a sero-survey Teenager/Adult (3) Malawi has not yet conducted a sero-survey 16
Designing A Specific Approach or Strategy for Closing Immunity Gaps (1) How did you design a specific approach or strategy for closing immunity gaps, if any? (describe main facilitators and barriers for action) 17
Designing A Specific Approach or Strategy for Closing Immunity Gaps (2) 1. Epidemiological trends and Case Fatality rates were calculated during the 2010 Measles outbreak. The geographical and landscape of the area affected Availability of Facilities to be used as vaccination sites The number of vaccinators to be involved, versus those available 18
Designing A Specific Approach or Strategy for Closing Immunity Gaps (3) 2. Conducting SIA targeting a wider age group for closing immunity gaps Malawi targeted a wider age group in the catch up campaign of 1998 and the follow up campaign of 2010. The 1998 catch up campaign resulted in closing the measles wards in hospitals. Conducting an MR SIA prior to the introduction of MR targeting a wider age group, ie, 15 years. Malawi is due to for introduction of MR early 2017. 19
Designing A Specific Approach or Strategy for Closing Immunity Gaps (2) 3. Provision of High Routine Immunization Providing high vaccination coverage 80% with at 1 dose of measles- and rubella- containing vaccines to avoid the paradoxical effect. Achieving high and homogenous vaccination coverage through routine immunization services to reduce the pool of susceptible children. 20
Designing A Specific Approach or Strategy for Closing Immunity Gaps (2) 4. Use of Periodic Intensified Routine Immunization (PIRI) Admin coverage is closely monitored for health facilities and districts. Where low coverage of <80% is noted, Periodic Intensified Routine Immunization (PIRI) is organized. 21
Approaches and Strategies Describing the approach and challenges in terms of: Political commitment Strategies Advocacy tools Financing Oversight Sustainability 22
Political Commitment (1) There is high political commitment in the country MCV1 coverage is a CABS (Common Approach to Budgetary Support) indicator hence closely monitored by MoF. GoM procures all the Measles vaccines for the country through the national budget and government resources 23
Political Commitment (2) Politicians participate to the cause of immunization during routine immunization and Supplemental Immunization Activities (SIAs) o During SIAs Members of Parliament (MPs) provide their resources to support the activity o Launch for introduction of new vaccines and SIAs is done by high level politicians Challenges Financial constraints resulting if reduced budget for Immunization programme 24
Strategies (1) 1.Identify and examine reasons for unvaccinated and undervaccinated populations Programmed has mapped out hard to reach areas and the socially never reached populations Deploy mobile teams to hard to reach areas Conduct defaulter tracing Involve communities Construct under five clinic shelters [41% of outreach clinics are conducted under a tree (2,020/4,894)] 25
Strategies (2) 2. Update microplans to ensure that all communities are included and targeted within session plan Train health facility workers in micro-plans through REC approach Develop and distribute microplanning tools Involve communities Conduct Periodic Intensification of routine immunization Operationalize use of Village Health Register Conduct defaulter tracing 26
Strategies (3) 3. Prioritize services to reach the largest number of unvaccinated Map up populations in had to reach areas. Malawi has already mapped this population according to distance, mountains, rivers, lakes and swamps/march including forest reserve. Deploy mobile and house to house teams Involve communities Conduct defaulter tracing 27
Strategies (4) 5. Revitalize and provide adequate resources for outreach services Open new outreach clinics in hard to reach areas Rescheduling cancelled outreach clinics Provide adequate resources to operation of outreach clinics Involve communities in the operation of outreach clinics 28
Strategies (5) 5. Apply Periodic Intensification of Routine Immunization (PIRI) in settings requiring rapid, short-term coverage improvement or catch up missed vaccinations Conduct Periodic Intensification of Routine Immunization (PIRI) in hard to reach areas. Linking microplanning and defaulter tracing with PIRI 29
Strategies (6) 6. Avoid missed opportunities Immunize children and mothers at every contact Review child or mother s record for immunization False contraindications 7. Ensure ongoing refresher and in-service training and performance improvement of vaccinators and peripheral managers and supervisor Provide training in IIP, REC Approach, MLM, Data Management Conduct review meetings 30
Strategies (7) 7. Develop and disseminate up-to-date pre-service immunization training packages Conduct trainings for tutors in training institutions, provide materials Conduct supervision on implementation of the protype curricula Conduct meeting with tutors annually 8. Maintain a functioning cold chain and vaccine distribution system 31
Challenge for RI Strategies (8) Immunization is done by HSAs who need transport provision in order to reach out to outreach sites Financial constraints field allowances for HSAs conducting outreach clinics Shortage and scarcity of kerosene and gas for cold chain Absence of Health Facilities micro plans in most of the districts visited Lack of reliable (or multiple) sources of demographic data for calculating target populations Many clinics cancel planned outreach sessions as a result of logistics challenges (transport push bikes, fuel) 32
Challenge for RI Strategies (9) There is no RED/REC field guide to reach the unreached Two different systems (DHIS and DVDMT) reporting different information, lack of data sharing, harmonization and access to DHIS. Absence of immunization charts in the majority of health facilities, where available some are wrongly drawn and not displayed. Monthly reports were missing in some health facilities and the reports were not properly filled. Immunization performance and disease trends not being monitored 33
Challenge for RI Strategies (10) No mechanisms to track defaulters Most of supervision to HFs do not offer comprehensive support All supervisors do not give written instructions/action points 34
Advocacy Tools (1) EPI communication plan in place 2016-2020 cmyp in place Resource mobilization concept note Briefing note to donor partners 35
Financing (1) Advocacy for more resources for RI using the advocacy tool Regular meetings with the Parliamentary Committee on Health (PCH) Regular engagement of donor partners through ICC (EPI Sub- Technical Working Group-TWG) EPI is an integral part of the Essential Health Package (EHP) with budget line for vaccine and supply procurement, including the co-financing for new vaccines Program receives significant technical and financial support from Health Development Partners (HDPs) Reference: Combined EPI Comprehensive and surveillance (Sep/Oct 2015) 36
Financing (3) Challenges Decline in funding for the health sector, resulting in significant reduction of available funds for the immunization program. The recourse to borrowing from the domestic market by government to close funding gaps has resulted in increases in the cost of health service delivery in the country There is inadequate alignment and coordination of HDPs financial systems with those of the government Inadequate capacity for financial management, including the tracking of fund flow from one level to another and within the districts Reference: Combined EPI Comprehensive and surveillance (Sep/Oct 2015) 37
Oversight (1) At the district level, immunization is coordinated and managed through the District Health Management Team (DHMT) Existence of HSRG/HSWG (Health Sector Working Group) supported by a technical working group, though NITAG is still under creation Coordination of HDP technical and financial inputs done through the technical working group (TWG) Existence of the National Immunization Technical Advisory Group (NITAG) 38
Oversight (2) Challenges Not all NITAG members were trained due to different individual commitments National AEFI Committee not yet established 39
Sustainability (1) Presence of line item for immunization in the health budget Procurement of traditional vaccines by government with support from HDP Government has never defaulted in its co-financing commitment Gavi HSS (HSS 1) funds used to address health systems barriers to immunization HDPs mobilize resources to close gaps in Government funding for the program At district level, budget for EPI included in the overall district EHP budget Reference: Combined EPI Comprehensive and surveillance (Sep/Oct 2015) 40
Sustainability (2) Challenges There is a significant shortfall of program financing in 2015/2016 at national level, with only 3% of total EPI budget for operations is available. Over-dependence on external donors/partners funds for cold chain equipment and other program operations including, supportive supervision, outreach sessions, active surveillance Funds available for immunization at district level mostly for logistics, with limited funds for outreach services, supportive supervision etc. Reference: Combined EPI Comprehensive and surveillance (Sep/Oct 2015) 41
Measuring Success of The Approach or Strategies (1) Measuring success of the approach or strategies is done through surveys and assessments. 42
Measuring Success of The Approach or Strategies (1) Routine Monitoring of MCV coverage by strategy (fixed versus static) and for each Health facility. The target is >80% coverage Periodic Coverage surveys for Routine immunization Post campaign coverage survey Monitoring of MCV coverage for each Health facility. The target is >95 % coverage 43
Measuring Success of The Approach or Strategies (2) Malawi conducted the following assessments o Data Quality Self-Assessment (DQS)-2014 o Cold Chain Inventory (CCI)Assessment- December 2014 o Missed Opportunities for Vaccination (MoV)- 2015 o Combined EPI Comprehensive and Surveillance review-september/october 2015 44
Measuring Success of The Approach or Strategies (3) Planned Assessments: o Effective Vaccine Management Assessment (EVMA)-June 2016 o Post MR SIA coverage survey-2017 o KAP Study-2017 o Stock availability study-2017 45
Monitoring and Vaccination Strategies Based on your experience, what monitoring and vaccination strategies would you use in the future, if the problem continues or returns? 46
Monitoring Strategies To Use In Future Harmonizing and sharing information between DHIS and DVDMT and reporting same information. Provision and updating monitoring tools Provision of refresher training on use of electronic data management (DVDMT/SMT). Monitoring immunization performance and disease trends through EPI monitoring charts and tables. Using a defaulter tracking system to track defaults Regular review meetings and supportive supervision 47
Vaccination Strategies To Use In Future (2) Deployment of mobile teams in hard to reach areas Deployment of House to house teams Provision of technical and financial support to immunization Developing district and health facility micro plans based on the REC approach Provision of support to strengthen ICC/EPI-Sub TWG Addressing gaps in quantity and quality for human resource, especially at districts and health facility levels Mobilizing more resources for RI from government and donor partners. Putting in place mechanisms to track flow of funds from national to districts to health facilities Provision of adequate transport 48
End of Presentation Thank You 49 16/05/2016 49