Child health

Supporting Access to Immunization through Supplementary Immunization Activities

By Abubakar Shehu and Emerald Awa- Agwu

Supplementary Immunization Activities (SIAs) are one of the four strategies put forward by the Global Polio Eradication Initiative (GPEI) in 1988. In Nigeria, SIAs include Immunization Plus Days (IPDs), Outbreak Responses (OBRs) and other immunization outreaches conducted by the Nigerian government and its polio eradication partners. The aim of SIAs is to interrupt the transmission of the poliovirus by immunizing all children under five years of age with two doses of oral polio vaccine irrespective of their previous immunization status—unimmunized, partially covered or fully immunized.

A child receiving the Oral Polio Vaccine

A child receiving the Oral Polio Vaccine

SIAs are intended to complement Routine Immunization. However, in some areas, they represent the major strategy for catching unimmunized children and ensuring that they are vaccinated against polio and other vaccine-preventable diseases. Access to routine immunization services may be hindered for a variety of reasons including:

  • Challenges with cold chain equipment leading to vaccine damage and loss of potency, and eventually, unavailability of vaccines. Caregivers are often reluctant to return to health facilities where vaccines were unavailable. This results in missed opportunities to commence or complete the vaccination course.

  • Security challenges that make health facilities hard to reach by caregivers who bring children for immunization.

  • Access-related challenges such as caregivers having to travel long distances to the health facility or being unable to afford the cost of transportation

  • Wrong myths or perceptions about vaccinations such as loss of fertility as a result of vaccination.

SIAs take immunization services directly to children at their doorsteps, thereby bridging any gaps that may result from an inability to access vaccines at the health facilities. By achieving a vaccination coverage of at least 80% (that is, by vaccinating at least 80% of the targeted children with a potent vaccine), herd immunity can be achieved and the poliovirus can be deprived of the susceptible hosts which it needs to survive.

Through Supplementary Immunization Activities, children who were missed by routine immunization services can be reached with life-saving vaccines

Through Supplementary Immunization Activities, children who were missed by routine immunization services can be reached with life-saving vaccines

Prior to 2012, Nigeria had been conducting SIAs but was still recording cases of wild poliovirus (WPV). After a holistic examination of the immunization program, it was discovered that there was a huge disparity between the actual versus reported immunization coverage. Reports from independent monitoring and supervision groups showed that the actual vaccination coverage of the SIAs was much lower than the reported coverage. There were many missed settlements and an even larger number of missed children. It was discovered that some vaccination teams never visited the communities, instead, they would discard the vaccines and record false information in the tally sheets to account for the empty vials. Not only was this frustrating the polio eradication efforts, but it was also causing the health system huge losses as a result of the wasted vaccines.

It became imperative to develop a methodology to improve vaccination coverage and ensure that the vaccination teams visited all the target settlements during SIAs. This led to the development and deployment of the Vaccination Tracking System (VTS) in 2012.

VTS provides healthcare administrators and partners in the polio eradication space with daily insight into the activities of vaccination teams during SIAs by collecting passive tracks of the vaccination teams using Geographic Information Systems (GIS technology-enabled android phones and uploading them onto a dashboard for visualization. This provides stakeholders with near-live data about the geo-coverage of the vaccination campaign. The system also identifies missed settlements on a daily basis so that immediate action can be taken and the settlements can be included in the ongoing campaign. Another benefit of the VTS is that it increases the accountability of vaccination teams because the vaccinators know that they are under constant supervision. This greatly reduces the risk of data falsification.

The VTS dashboard provides decision-makers with near-real-time data about the progress of immunization campaigns and outreaches

The VTS dashboard provides decision-makers with near-real-time data about the progress of immunization campaigns and outreaches

So far, VTS has been used to track 82 supplementary immunization activities in 30 states of Nigeria. A significant proportion of these states have seen an exponential increase in the vaccination geo-coverage rates from the first campaign tracked to the last tracked campaign.

Increase in vaccination coverage rates

Increase in vaccination coverage rates

VTS makes sure that eligible children who, for any reason, are unable to receive their vaccinations through the routine immunization sessions at the health facilities, have a second chance to be protected against vaccine-preventable diseases like Polio and Meningitis.

The Importance of High-Quality AFP Surveillance Data in the Fight to Eradicate Polio

Polio is targeted for eradication because the presence of the virus anywhere means that children everywhere are at risk. The Global Polio Eradication Initiative (GPEI) focuses on strengthening Acute Flaccid Paralysis (AFP) surveillance worldwide to detect and respond to the poliovirus, to build herd immunity to protect the population and to halt the transmission of the virus. The data on the spread of AFP is invaluable especially for polio-endemic countries like Afghanistan, Pakistan, and Nigeria because it helps in determining whether they can finally be certified polio-free.

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There are four steps involved in AFP surveillance and the Auto- Visual AFP Detection and Reporting (AVADAR) project responds to the first step—finding and reporting children with AFP—in eight priority countries in Africa. In many of these countries, disease surveillance and notification officers (DSNOs) at the health facilities are unable to actively find AFP cases for reasons ranging from difficulty in accessing settlements to security challenges. AVADAR trains community informants to search for and report the presence and/or absence of children with AFP in their community, using a mobile application. The application also has an embedded video that shows a child with AFP so that community informants can better recognize an AFP case. This reduces the burden on the DSNOs and allows them to focus on confirming if the case is truly AFP or not.

How AVADAR works

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To ensure that AFP surveillance is conducted impactfully and that the AFP surveillance data collected is accurate, timely and of high quality, the GPEI defined five global indicators: Completeness of reporting, Completeness of case investigation, Completeness of follow-up, Sensitivity of surveillance and Laboratory performance.

Global Polio Eradication Initiative: AFP Surveillance indicators

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AVADAR was designed by eHealth Africa, Novel-T, the World Health Organization (WHO) and other partners, to contribute to the achievement of the above targets. Below are the measures that have been put in place to ensure the collection and use of high-quality data to track and reports suspected AFP cases, and to inform decision making for polio eradication.

  • Coverage: To decide where to site an AVADAR system, WHO carries out an assessment of the target country/districts to identify rural, hard-to-reach and underserved communities which are typically more predisposed to poliomyelitis. The AVADAR system, equipped with geospatial tracking capabilities is then deployed to community informants/ AFP reporters. This unique feature of the application helps to validate the location of the suspected AFP case, independent of the reporter.  

  • Reporting: The AVADAR application allows informants to deliver reports anywhere and anytime in order to prevent data loss and to ensure near real-time, accurate reporting.  The app is designed to be used by people with basic literacy levels and is available in eighteen local African languages for ease of understanding. A report is better able to provide insight and enhance planning or decision making when it is timely. One of the key weekly metrics captured on the AVADAR dashboard is the number of complete results that were submitted as at when due, thus ensuring that all informants are actively engaged. Informants are expected to look out for and report cases of children aged 15 years and below, who have any form of physical deformity on the limbs or arms. In the event that no AFP case has been sighted within a week, the informant must send a ‘no report’, to validate his presence on the system.  

    AVADAR has improved the rate of AFP reporting compared to the traditional system of AFP reporting. For example, between June 2017 and June 2018 in the Lake Chad Basin countries(Chad, Niger, Nigeria, and Cameroon), the AVADAR system recorded 589 supsected cases against the 213 cases recorded by the traditional AFP Surveillance system.

  • Verification: Paralysis in children can be caused by several agents including the Poliovirus. After the community informants submit their reports of suspected AFP cases, trained health workers carry out further investigations to confirm if they are true AFP cases. The WHO has designated laboratories all over target countries that are certified to test fecal samples and isolate the poliovirus. AVADAR weekly reports show how many suspected AFP cases were reported, how many were tested and the number of cases confirmed to be true AFP cases. This sort of data measures the cost of a single confirmed AFP case, the prevalence and incidence of AFP in target areas, thus enhancing the quality of AFP surveillance data for decision making.

AVADAR dashboard

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Having data on the spread of AFP in a geographic location helps with planning towards its containment. Since Poliomyelitis is mainly oral-fecally transmitted, sanitization and sensitization of the environment and inhabitants respectively can help reduce the spread of polio.  AFP data gathered across different locations has been used in making an informed decision on determining the number of health workers that can effectively manage its spread to neighboring communities. On the contrary, no data or false data could lead to health workers focusing their energy in wrong locations thereby risking the spread of polio and the extension of its existence.

Without reliable and accurate AFP surveillance data, true progress towards polio eradication cannot be measured. AVADAR’s impact in high-risk countries across Africa demonstrates how context-appropriate interventions and solutions can transform disease surveillance and emergency management systems.

One of the most important features of the AVADAR system is the engagement of over a hundred community informants per county. They are trained and equipped for the first time to provide timely reports that can be accessed at all levels from the county to the national level and beyond, thereby allowing suspected cases to be investigated in an accurate and efficient way.
— Dr Sylvester Maleghemi, WHO Polio Eradication Initiative Team Lead, South Sudan

Benefits of a Direct Delivery Model

By Adamu Lawan and Emerald Awa- Agwu

eHealth Africa's third- party logistics service, VDD ensures that vaccines are delivered to last mile health facilities in a timely manner

eHealth Africa's third- party logistics service, VDD ensures that vaccines are delivered to last mile health facilities in a timely manner

Vaccination is one of public health’s most cost-effective interventions. According to the World Health Organization1, it prevents between 2 million to 3 million deaths every year. Even though there has been great progress towards achieving universal coverage, there are still 20 million unvaccinated and under-vaccinated children worldwide. To reach these children and to meet global disease elimination targets, all countries must provide an uninterrupted supply of potent vaccines to the most hard-to-reach and conflict-affected areas.

Nigeria has experienced challenges in maintaining functional vaccine cold chains and supply chains, leading to low vaccination coverage rates. Nigeria’s cold chain system consists of five levels: a national cold store which stores all vaccines in the country and supplies six zonal cold stores located in each of Nigeria’s six geopolitical zones. The zonal stores supply vaccines to the state cold stores, which in turn supply the LGA cold stores. The primary health care facilities staff have to visit the LGA cold stores to collect their vaccines on a weekly or daily basis depending on the status of their cold chain equipment.

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This system was inefficient and time- consuming because health workers from over 9,000 health facilities in Nigeria often had to leave work to collect vaccines when they could be treating patients instead. In addition, the system was fraught with high operational costs and poor vaccine stock visibility, especially in transit.

To alleviate this problem, the Nigerian government adopted a direct delivery model called Push Plus in 2013, to transform its supply chain at the state level. A direct delivery model is one which delivers vaccines and dry goods directly from the state cold store to the last mile health facilities according to customized schedules, bypassing the LGA warehouses completely and preventing stock-outs.

The benefits of this model have been enormous. The direct delivery model has freed up an additional 1- 6 hours each week for health workers to attend to patients—time previously spent by health workers in transit to obtain vaccines. In addition, vaccine availability at the last mile health facilities has improved. By increasing the number of health facilities that have functional cold chain equipment, health posts and smaller health facilities can receive vaccines from closer health facilities instead of going to the LGA cold store every day. This has led to a massive drop in the stock-out rate. In Kano state, vaccine stock-out rates dropped from 93% to 3% and in Lagos State, from 43% to none. Not surprisingly, the immunization coverage of Lagos State increased from 57% to 88%. WHO2 lists vaccine shortages and stock-outs as a major cause of missed opportunities to vaccinate.

Nigeria is projected to spend about US$ 450 million by 2020 on vaccines, By increasing vaccine accountability and visibility, the direct delivery model has also reduced the amount of money that could be lost due to wastage and pilfering of vaccines.

eHealth Africa implemented Vaccine Direct Delivery, a third-party logistics service based on the direct delivery model in Kano State from 2014 to 2016 and currently implements it in Bauchi and Sokoto states. We work with the state primary healthcare development agencies to ensure that vaccines and dry goods are delivered safely and in a timely manner to health facilities. Using our LoMIS Deliver solution, eHA plans, schedules, and routes deliveries to enable health delivery officers choose the correct quantity of vaccines and dry goods from the state cold stores and deliver them to health facilities equipped with cold chain equipment. The process of determining what quantities to deliver at the health facility is fully automated to avoid manual errors. The project also incorporates reverse logistics—returning balance stock or waste, if any to the state cold store. VDD provides governments and other stakeholders with accurate, near real-time data for decision making and forecasting.

Through VDD, over 28 million doses of vaccines have been delivered to health facilities in Kano, Bauchi and Sokoto State from 2014 to date, reaching over 13 million children under the age of one. eHealth Africa continues to support governments across Africa with system-level approaches to transforming health service delivery.

World Sickle Cell Day: 6 facts you need to Know

By Emerald Awa- Agwu

Over 300,000 children worldwide are born with the Sickle Cell Disease (SCD), a genetic abnormality of the red blood cells in which they take a crescent or “sickle”- shaped appearance. Over half of these children die before the age of five.

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With over 300,000 babies born with the sickle cell disease every year, Nigeria has the highest burden of Sickle cell disorders in the world. The 19th of June every year is set aside to commemorate the World Sickle Cell Day. This year, we explore 6 facts you need to know about Sickle Cell Disease.

  1. Although sickle cell can affect people all around the world, the risk is higher in Africans or people of African descent.

  2. Sickle Cell Disease is not contagious or infectious.

  3. People who have the sickle cell disease may develop various complications such as anaemia, stroke, tissue, organ and bone damage as well as pain due to the inability of the sickle-shaped red blood cells to carry oxygen normally and to cause blockage of blood vessels.

  4. People with the genotype AS, are carriers of the Sickle Cell Trait (SCT) but do not suffer any symptoms of Sickle Cell Disease. They can however pass it on to their children.

  5. There is no cure for SCD yet. Although, some success has been recorded with bone marrow transplants.

  6. A person with SCD can live a long and active life as long as they undergo regular check-ups with a doctor, take their medications regularly, prevent infections through hygienic practices such as handwashing and drink lots of water.

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Currently, eHealth Africa is partnering with the University of Nebraska Medical Center (UNMC) and the International Foundation Against Infectious diseases in Nigeria (IFAIN) to implement a clinical trial of the HemeChip, a device that can detect the sickle cell gene in babies as young as 6 weeks old using little to no electricity. The HemeChip is a component of SMART (Sickle and Malaria Accurate Remote Testing), a solution that recently won eHA and its partners, Case Western Reserve University, Hemex Health and the University of Nebraska Medical Center (UNMC), the Vodafone Wireless Initiative Project prize. SMART is designed to diagnose, track and monitor sickle cell disease and malaria in low resource settings.

This World Sickle Cell Day, eHealth Africa encourages everyone to get screened. Discovering one’s genotype is the first step in reducing the incidence of Sickle Cell Disease and preventing any more deaths and complications from occurring.