Achievements and challenges in routine immunization Eastern

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Achievements and challenges in routine
immunization- Eastern Southern Africa

• Task Force on Immunization Meeting
• Luanda, Angola
• 2 5 December 2003
• Mr. R. Davis
• UNICEF/ESARO Regional EPI Advisor
• On behalf of ESA Regional Working Group

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Routine EPI Status Eastern Africa
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Routine DTP3 coverage 2nd quarter 2003
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Monthly EPI Summary
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Routine EPI Status Southern Africa
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DPT3 coverage, Southern Africa, Jan-Dec 2002
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Distribution of DPT3 coverage ranges by
districts, Southern Africa, 2002
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Distribution of DPT dropout rates by districts,
Southern Africa, 2002
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Factors affecting decline in DPT3 in selected
Southern African countries

• Madagascar may have exaggerated reported coverage
  in 2001, so that the coverage reported in 2002 is
  more realistic.
• Malawi reported 79 for OPV3 and 64 for
  DPT-HepBHib3 (pentavalent) vaccine in 2002. It
  appears that DPT3 data for the first 2 months of
  the year were lost during the switch to the new
  vaccine.
• Zimbabwe is suffering the impact of an economic
  crisis which, in 2002, caused temporary vaccine
  stock-outs, shortages of fuel for transport and
  cold chain, and exacerbated the attrition of
  human resources.

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Five operational components needed to reach
every district

• Re-establishment of outreach services
• regular outreach for communities with poor access
• Supportive supervision
• on site training by supervisors
• Community links with service delivery
• regular meetings between community and health
  staff
• Monitoring and use of data for action
• chart doses, map population in each health
  facility
• Planning and management of resources
• better management of human and financial
  resources

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Concepts at work

• Describe target population and coverage
• Locations, characteristics, size, coverage,
  unimmunized
• Analysis of the barriers to high coverage
• Numerical problem description, qualitative
  problem description, existing solutions
• Prioritize
• Use of resource efficiently!
• Look at unimmunized children as well
• District activity plan the heartof RED
• Session / outreach / personal workplans
• Include logistics planning, vaccine management,
  transport, injection safety, programme
  integration, resource availability
• Monitor implementation
• Ongoing process, cannot stop, cannot be late
• Feedback to providers of the information
  essential
• Flexibility - data must be able to change the
  activity

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Routine vaccination support existing projects
eg. Ethiopia

• USAID funded project
• Focus on capacity building and integration
• MoU with 6 partners, but hampered by system
  problems
• Produced zonal microplanning
• Using SO for routine EPI
• Surv Officers TORs focus on routine EPI support
  including sensitization, vaccine mngt, collect /
  compile EPI data, local coordination with NGOs,
  supportive supervision, training
• Careful documentation

• Addressing access issues
• Decentralization in a crucial transition time
• Target 6 areas including strengthening routine,
  capacity building, data management, vaccine mgt,
  IEC and communication and monitoring and
  evaluation
• Use of data for the categorization of woerdas
• Community participation to improve EPI in Amhara
• Advocacy of the heads of woredas during the
  decentralization process
• Megastawi Buden

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But

• RED, drop-out reduction, expansion of outreaches,
  district microplanning is more than a passing
  project it is central to routine vaccination
  improvement
• Roll-out to all districts is essential to reap
  benefits of the projects started

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Status of new vaccines in Eastern Southern
Africa
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New vaccines introduction E S Africa, Nov 2003
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Challenges New vaccinesEnsuring supply!

• Case study Uganda

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Causes of the Ugandan Pentavalent Vaccine Stockout
VACCINE FORECAST SUPPLY ISSUES
VACCINE MANUFACTURER ISSUES
UGANDA PENTAVALENT STOCKOUT
USE OF VACCINES IN-COUNTRY
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Using DTP3 for forecasting
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Uganda DTP stopgap measure
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Estimated (VF and shipments) and reported stocks
Balance
Balance
Buffer
Buffer
2002
2003
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Awards vs. implementation

• Award and review of needs done on annual basis
• For DTP-HBHib, wastage of 5 (based on penta3)
  has been difficult to achieve. This has resulted
  in reduced stocks in countries that meet coverage
  targets.
• High drop-out rates (specially for DTP-HBHib)
  can result in an increase of needs that cannot be
  meet by the GAVI support.
• Monitoring of stocks and utilization is
  essential to ensure availability. Only this can
  identify changes needed in shipments and GAVI
  support.

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Where is hep B vaccination moving us?

• HBV vaccine is highly effective within the
  framework of the South African EPI and already
  shows a positive impact in the elimination of
  HBsAg carrier rate in childrenlt5 years. K. V.
  Tsebe et al., The first five years of universal
  hepatitis B vaccination in South Africa
• Is hep B poised to surpass measles as the leading
  cause of vaccine preventable mortality in
  sub-Saharan Africa?
• Should we be vaccinating clinical personnel?
• Can we aim for zero hep B associated mortality in
  new birth cohorts?

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ASANTE SANA MILLE GRAZIE BINOBODONDI NATONDI B
EDANKT MERCI BAIE DANKIE OBRIGADO DHANJABHAT
OKUHEPA DJERE DIEUFECHE DADA PANDU DEUS
PAGARAPUSUNKI (QUECHUA) HVALA REALEBOGA KEAITU
METSE SHUKRAN MAZVITA SIYABONGA MUCHAS
GRACIAS SPASIBA OKUHEPA THANK
YOU TWATOTELA TWATASHA TATENDA VIELEN
DANK MWASHUMA ZIKOMO KANIMAMBO YIN ACA
LEEC NAGODE ESE KE EA LEBOHA SOSONGO MEDASE
KEALEBOHA
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The End
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Additional slides

• For inclusion in CD-ROM

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Observations Access and utilization

• When Angola is excluded, reported DPT1 coverage
  (a surrogate for access to immunization services)
  declined from 92 to 86 between 2001 and 2002.
  Hence, in general, access to services appears to
  have declined.
• When Angola is excluded, reported DPT3 coverage
  (a surrogate for utilization of immunization
  services) declined from 78 to 74 between 2001
  and 2002. Furthermore, DPT1-DPT3 drop-out rates
  increased from 10 to 17 during 2001-02. Hence,
  drop-out has increased markedly.

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Reported DPT3 coverage by country,Southern
Africa, 2002 gains made since 1995
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Reported DPT3 coverage,Southern Africa, 1990-2002
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Basic anomalies with JRF reports

• Botswana, Lesotho and Namibia reduced the target
  number of infants lt1 year of age by gt20 between
  2001 and 2002.
• In 2001, DPT3 coverage exceeded DPT1 coverage in
  Mauritius and Namibia.
• Zambias health information system does not allow
  for reporting DPT1 coverage, which makes it
  impossible to monitor drop-out rates.
• During a national EPI review in Seychelles in
  June 2003, it was noted that reported coverage
  was under-estimated. In fact, DPT1 and DPT3
  coverage in 2002 were both 100.

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Factors affecting accuracy of reported coverage
rates, 2002
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DPT stock out rates by district and national
wastage rates, Southern block, 2002
Open vial policy currently being implemented in
all countries except Zambia
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Injection safety in Southern Africa, 2002
All countries have waste management policies
(incineration and burning)
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Distribution of countries with 3-5 year EPI
strategic plans of action
No plan
Plans exist
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Distribution of routine EPI funding in Southern
Africa, 2002
ND
1- 50
51 100
Seychelles funds 100 of the EPI programme
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Challenges on EPI performance

• To increase vaccination coverage
• To improve systems performance (dropouts,
  stock-outs,wastage etc.)
• To improve injection safety
• To improve on monthly/quarterly EPI reporting
  from countries
• To increase govt. funding for EPI

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Way forward for routine EPI

• To assist countries with development of good EPI
  micro-plans at all levels
• To create demand for vaccination services through
  social mobilization
• To improve vaccines management
• To strengthen outreach services for hard to reach
  areas
• To use new innovations in injection safety, such
  as AD syringes
• To regularly monitor systems performance and
  quality of data for re-directing national
  programmes
• To advocate for increased national financing for
  EPI services

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Opportunities in countries

• ICCs in place in countries. Can be used to
  mobilize resources from partners to support the
  micro-plans
• GAVI funds in countries
• MLM funds for strengthening capacity and training
• WHO focal points in countries

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Routine vaccination support existing projects
eg. Uganda

• SOS
• Integration works, especially if basic services
  access 49!
• Outreaches are essential to improve coverage in
  hard to reach areas
• BASICS II
• Community Problem Solving and Strategy
  Development
• Community linkages Active monitoring
• Problem solved by the people affected by it!

• EPI/IDSR Supportive Supervision
• Establish intermediary level supervisors
• Link programme and surveillance supervision
• Regional Center for the Quality of Health Care
• Create and agree on stakeholder agreement
• Development of National Performance Standards
• Using EPI Systems approach

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The 5 wastage issue