Pushing the Boundaries of Routine Immunization coverage

By John Momoh & Emerald Awa-Agwu

In 2017, following the results of the 2016-2017 Multiple Indicator Cluster Survey/ National Immunization Coverage Survey (MICS/NICS) Report, which put Nigeria’s routine immunization (RI) coverage rate at 33%,  the National Primary Health Care Development Agency (NPHCDA) declared a state of emergency on RI in Nigeria 1. This led to the establishment of the National Emergency Routine Immunization Coordination Centre (NERRIC) and its state-level counterparts, across the 36 states of the federation. NERICC and SERICC targeted states and local government areas that had low immunization coverage rates with various interventions, aimed at attaining a RI coverage rate of 84% by 2028. The majority of states in this category are in Northern Nigeria 2. 

Many reasons exist for low vaccination coverage rate including non-compliance by households, insufficient vaccines, health workers, and/or health facilities to meet the demand for immunization services. However, what happens when you have all these factors combined with insecurity, displacement of people, and physical destruction of health facilities?

eHA consultant in Magumeri LGA training the LGA RIE team on the use of electronic data collection methods

It’s an Emergency
The insurgency in Northeast Nigeria has been ongoing since 2009 and the current reality is that health workers and households face grave challenges delivering and accessing RI services. There are issues of security to consider as well as the migration/abandonment of settlements which hinder proper planning and execution of routine and supplementary immunization activities (SIAs). This has led to consistently underserved populations and thus, low immunization coverage rates.

eHA consultant in Biu LGA supporting the LGA RI Officer to micro-plan using GIS Maps

The Strategy
To alleviate this, the Borno State Emergency Routine Immunization Coordination Centre, in close collaboration with partners including the World Health Organization (WHO), Rotary International, the U.S. Centers for Disease Control and Prevention (CDC), the United Nations Children’s Fund (UNICEF), the Bill & Melinda Gates Foundation (BMGF), eHealth Africa (eHA), Solina Health, and Novel-T launched the Routine Immunization Expansion (RIE) strategy to expand RI activities to security-challenged areas in order to improve the coverage rates. This strategy uses Geographic Information Systems (GIS) solutions as the basis to identify and target settlements for RI sessions and provide proof of visitation, thereby, improving routine immunization coverage.

eHealth Africa's Role
We have leveraged our expertise in data management solutions and Geographic Information Systems (GIS), to provide end-to-end support for the implementation of the RIE strategy in Borno. We provide the RI teams with up-to-date GIS maps and a list of settlements that they use during their microplanning activity to estimate target populations and allocate catchment areas to health facilities across the state. Using these tools and local knowledge, the teams prioritize and plan what areas to reach using criteria like accessibility, habitation status, and the proximity to adjoining settlements. Furthermore, this allows each LGA to estimate the optimal number of teams and days required to cover all their targeted settlements for each round of RIE implementation. This process is critical to the program because it has a direct impact on logistics and finance planning. During RIE field implementation activities, we monitor RI teams’ coverage in security-compromised areas using GPS-enabled Android phones, similar to what occurs in the Vaccinator Tracking System project.

At the end of each round, we develop a post-implementation report and updated map which are shared with the relevant stakeholders for informed decision-making and progress monitoring.

The Progress So Far

As a result of using GIS technology, routine immunization coverage in security-challenged areas in Borno has increased from 12% in April 2019 to 88% in December 2019.

These results show the significant impact that innovative data solutions and GIS technology, combined with contextual insight and partnership can have on health interventions in low-resource settings.

Building Local Capacity and Infrastructure for Disease Surveillance in Africa

By Chinedu Anarado

Nigeria is the only country in Africa where polio is still endemic, however, the continent is still at risk of polio returning due to low immunity levels and weak surveillance systems.  Since 2016, the AVADAR project has been implemented in 8 countries across West and Central Africa to improve the quality and sensitivity of Acute Flaccid Paralysis (AFP) surveillance by health workers and key informants within health facilities and local communities, using mobile phones and an SMS based software application. eHealth Africa trained a total of 7,847 community informants to identify and report suspected cases of AFP, which is the defining symptom of Polio.

The AVADAR mobile application

The project increased the rate of AFP detection and reporting and put the implementing countries in a better position to meet the World Health Organization’s targets for AFP surveillance. In the Democratic Republic of Congo (DRC), for example, a total of 499 true AFP cases have been reported by community informants through AVADAR, a significant improvement over traditional paper-based surveillance systems which yielded 38 cases in the same period.

The Challenge

Our goal was to model a system that would enable health systems in the implementing countries to find, report and investigate AFP cases, and that would be sustainable in the long run. It became imperative for the health systems in these countries to take ownership of and lead the implementation and expansion of the AVADAR model, and possibly replicate it for the surveillance, reporting, and investigation of other diseases of public health concern. However, without the requisite skills, most countries will fail at effectively managing the system including reporting and managing the investigation of cases, and tracking and resolving technical issues.

The Strategy

Relying on our experience with the execution of AVADAR, where some informants were groomed to take on more roles on the project, we worked with the WHO to identify champion informants who had distinguished themselves through their timeliness on the system and technical aptitude with the AVADAR devices. Some of these informants were trained to serve as investigators—who track and review reported AFP cases to confirm if they are true or not—or as technical officers, who resolve technical issues and ensure that their fellow informants are able to continue reporting suspected AFP cases.

The technical officers were grouped into two categories: first-level and second-level technical support officers. The first-level technical officers serve as the first point of contact when an informant has technical challenges with his/her device. When they are unable to resolve these issues, they escalate the challenge to the second-level technical support officers, who are usually WHO staff or investigators within the country ministries of health, with superior technical skills. The second level support officers ensure that all issues are resolved and the AVADAR system can continue to work as expected.

The Success

So far, a total of 217 first level and 57 second-level informants have been trained across all the six countries eHA supported in 2019, as well as Liberia. eHA has now ended operations in four of these six countries— Chad, the Democratic Republic of Congo, Sierra Leone, and South Sudan and the trainees are now managing the network. The technical officers were trained using a two-step approach: theory-based training that took place in a classroom setting, and field practical sessions, giving trainees the opportunity to investigate and resolve real-life technical issues in the field. eHA continues to provide support in Cameroon and Niger, leading refresher training sessions for technical support officers, and resolving advanced technical issues in the two countries.

Some AVADAR informants are also going beyond polio to detect and report other priority diseases such as Measles, Yellow Fever, and Diarrhea in their communities using AVADAR. The flexibility of the AVADAR system and its potential to be used for reporting and detecting other priority diseases leaves no doubt that these countries are better equipped to prevent future outbreaks and protect their populations.

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

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

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

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

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.

Strengthening Routine Immunization using Lessons learned from Polio Emergency Support

By Joshua Ozugbakun & Emerald Awa-Agwu

In July 2016, after over two years of being polio-free, two wild poliovirus cases were discovered in Borno State, Nigeria. This launched fresh efforts to strengthen the four pillars of polio eradication including Routine Immunization (RI), Supplementary immunization activities (SIAs) (including national Immunization Plus Days (IPDs)), Surveillance and targeted mop-up campaigns.

A health worker vaccinates a child with the Oral Polio Vaccine

Partners, both local and international, collaborated with the Nigerian government at state and national level, through various interventions and projects to increase the coverage and effectiveness of IPDs and mop-up campaigns in order to increase herd immunity and stop polio transmission, especially in high-risk states like Adamawa, Borno and Yobe states. These interventions were coordinated by the State Emergency Routine Immunization Coordination Centers (SERICCs). Each SERICC is led by individual state governments and help to improve information sharing, joint programming of public health emergency management activities (planning, implementation, monitoring, and evaluation) with partners. The National Emergency Routine Immunization Coordination Center (NERICC) is responsible for strategy development and oversees the activities of all the SERICCs. With this coordination mechanism in place, the menace of polio is being tackled collaboratively and Nigeria is well underway to being declared ‘Polio Free’, a major milestone in its vaccine-preventable disease management efforts.
A major takeaway for Nigerian polio eradication stakeholders after years of battling polio is the need for data collection, management and storage systems to be upgraded. As the need to halt poliovirus transmission increased, it became increasingly obvious that paper-based data management systems were incapable of providing decision makers with the reliable, actionable data which they needed for effective programming. eHealth Africa responded to this challenge by supporting states across Nigeria to develop comprehensive, digital maps using our expertise in Geographic Information Systems (GIS). The accuracy of these maps improves the microplanning process and guarantees a greater coverage of settlements during campaigns.

Our GIS technology has improved the quality of maps used for polio campaign planning

In addition, through our Vaccinator Tracking Systems (VTS) project, GIS-encoded Android phones are used to record and store passive tracks of vaccinators as they conduct their house-to-house visits; allowing decision-makers to have an accurate picture of the settlements that have been covered during IPDS and mop-up campaigns. This data can easily be accessed through dashboards for a more detailed analysis and breakdown of coverage information.

Supporting polio emergency response activities also highlighted the need for the Nigerian health system to move from an emphasis on SIAs and campaigns to strengthening the RI and disease surveillance systems. Sound routine immunization and disease surveillance systems are necessary to sustain the herd immunity built through polio campaigns.

In Kano state, the LoMIS Stock solution helps the State Primary Health Care Management Board to ensure that the vaccine supply chain is maintained. Health workers at the facility level use the LoMIS Stock application to send reports on a variety of vaccine stock indicators including vaccine utilization, vaccine potency, stock levels, wastage rates, and cold chain equipment status. Supervisors access the reports through the LoMIS Stock dashboard and are able to respond appropriately. This ensures that the RI system is maintained and that health facilities are never out of stock.

In the past, Acute Flaccid Paralysis (AFP) surveillance in health systems across Africa was passive. This meant that disease surveillance and notification officers (DSNOs) only reported or investigated suspected AFP cases that were presented at the health facility. According to the U.S Centers for Disease Control and Prevention (CDC)1, over 72% of polio cases are asymptomatic and as such, will not present at the health facility. In addition, DSNOs are unable to visit every single community to actively search for AFP cases due to logistics and security challenges. Relying on data from passive AFP surveillance causes programs to be designed based on data that excludes the asymptomatic polio cases. Auto-Visual AFP Detection and Reporting (AVADAR) reduces the burden on the DSNOs by enlisting members of the community to actively find AFP cases and report using a mobile application on a weekly basis; thus, providing accurate real-time surveillance data that can be used for program planning and implementation.

An often overlooked factor that promoted the transmission of the poliovirus was the rejection of the polio vaccine by mothers and households due to various myths and socio-cultural barriers. By engaging traditional and religious leaders as ambassadors of vaccination, more mothers and households are accepting the polio virus.

The central lesson in Nigeria’s journey so far towards polio eradication is the importance of collaboration and engagement at all levels including communities. eHealth Africa is proud to be supporting governments and health systems across Africa to respond to the polio emergency.

eHealth Africa supports Sierra Leone’s Public Health Services for better response to public health emergencies

By Uche Ajene

The first-documented most widespread and deadly outbreak of the Ebola Virus Disease (EVD) in West Africa devastated three countries: Guinea, Liberia, and Sierra Leone. The outbreak started in May 2014 and by November 2014, during the height of the outbreak, Sierra Leone recorded over 500 new cases of Ebola a week. By October 2015, a total of 8,704 EVD cases had been diagnosed, and 3,589 people had died of Ebola in Sierra Leone.

This disease caught the country’s Ministry of Health and Sanitation (MoHS) by surprise. The outbreak could not be effectively managed because the country did not have the requisite capacity (structure and staff) and systems -Standard Operating Procedures (SOPs), policies and plans, to effectively manage and mitigate the risks posed by the disease.

Ebola’s destruction on the peoples of Sierra Leone and the absence of appropriate structures to deal with future outbreaks, prompted the establishment of Public Health National Emergency Operations Center (PHNEOC) in  June 2015, as a coordination structure charged with the responsibility of providing public health emergency preparedness leadership, scientific and technical situational awareness and advice at a national level.

As Sierra Leoneans reflect on the atrocities of Ebola and other emergencies, this question becomes inevitable: Is Sierra Leone better prepared to address any future public health emergencies?

To better prepare for future outbreaks, the U.S. Centers for Disease Control and Prevention (CDC), in collaboration with the Ministry of Health and Sanitation and eHealth Africa, conducted successful trainings for health workers and other stakeholders on Public Health Emergency Management, Risk Communication,Threat and Hazard Identification and Risk Assessment (THIRA), Incident Management Systems and Public Health Operations and Management. These training sessions were done in Bo, Bombali districts and Western Area Urban with the involvement of health workers, district councillors, the national security agency and members of the agricultural sector. These trainings are geared towards improving the PHNEOC’s capacity to better prepare for health-related emergencies.

The PHNEOC/MoHS as beneficiaries have acquired increased knowledge on the method of approach in risk mitigation, analysis, preparedness, response, and recovery. For instance, EOC Focal Persons have been trained in all districts in Sierra Leone to decentralize command and control approach which has provided the necessary pace, efficiency, and structure for response efforts and foster real-time reporting and bridged the gap in communication from the districts EOC’s to the national EOC. eHA, with support from CDC, has embarked on introducing tools that seek to improve the coordination strategy of the PHNEOC such as the Virtual  Emergency Operations Center (EOC) communication platform tool. eHA has partnered with MoHS with support from CDC to train about 200 PHNEOC/MoHS staff on various public health emergency topics such as tabletop simulation exercises on Cholera and Lassa Fever; Executive Management training and Virtual EOC training.

“I have participated in several trainings, I must confess that knowledge gained in this training is exceptional and can contribute meaningfully in any future outbreak and also benefit my District Health Management Team (DHMT) with management skills.”

— Sahr Amara Moiba

Virtual EOC training participants

Sahr Amara Moiba, District Surveillance Officer and EOC focal person in Kono district, is one of the 200 beneficiaries of the EMP training.

In 2018, there was a Measles outbreak in Pujehun and Kambia district. The EOC focal persons in these districts sent in a daily situational report to the national EOC which was presented to partners during the daily briefing meetings held at the EOC.

As part of the effort to strengthen the PHNEOC preparedness and response capacity, and also improve on the country’s Joint External Evaluation scores, eHA in collaboration with MoHS with support from CDC, developed SOPs for public health response. These SOPs will help improve on the response strategy of the PHNEOC in a coordinated way.

“These SOPs will help foster a coordinated response in an event of any public health emergency.”

— Mukeh Fambulleh, Program Manager of the PHNEOC

eHealth Africa and partners boost Sierra Leone’s surveillance capacity through 117 Call Center

By Uche Ajene

Photo caption: Alexander Taylor, 117 Call Center Manager conducted a tour of the upgraded facility

Between 2018 and 2019, eHealth Africa (eHA) and the Ministry of Health and Sanitation (MoHS) worked together to ensure that Sierra Leone’s surveillance efforts were strengthened through the use of 117 Call Center.

The 117 Call Center is a Sierra Leone Ministry of Health and Sanitation initiative that was set up in 2012 as part of a wider support system to improve maternal and child health. In 2014, eHA partnered with the Ministries of Health (MOH) in Guinea, Liberia, and Sierra Leone to scale up existing universal toll-free numbers to become Ebola focused call centers. The 117 Call Center was scaled-up in response to the Ebola Virus Disease (EVD) outbreak - to serve as a tool to document, track and provide follow-up on suspected EVD cases and deaths. The 117 Call Center provides an early warning mortality and syndromic surveillance system tool that can detect, prevent and respond to disease outbreaks. Communities are sensitized to call the 117  line and report all deaths, suspicious illnesses, and events. In Sierra Leone, the 117 Call Center has helped to solve many issues like improving community death reporting through mortality surveillance; real-time alert reporting for infectious death, increasing alert and data support to the maternal & perinatal disease surveillance.

Recently, the 117 Call Center has seen major transformation-from extending the facility and giving it a facelift, to upgrading software for a more efficient system that the peoples of Sierra Leone can trust and utilize.

“We have upgraded the call center software for a more accurate and precise data collection. Our community health workers play a very vital role in reporting cases to 117. We have added a new caller category of Community Health Workers. We also provided internet services for all the districts for real-time reporting and data collection for 117. We have also improved on our SMS software service that now provides a single text code to a caller to receive the burial code which confirms that they have indeed called 117.”

— Sally Williams, 117 Project Manager, eHA.

In an effort to get the districts more engaged, 117 is not just centralized in Freetown. Alert desks have been set up in all 14 districts with District and Data coordinators there to manage the calls in real time.

“The 117 Call Center is making positive strides in the country and the upgrade has taken it to international standard. 117 is easier to rebrand, given its popularity across the country.”

— Dr. A.J. Moosa, Deputy Director - Health Security and Emergency.

Strengthening the surveillance system in Sierra Leone through the 117 Call Center is an unending quest.

“We are planning on re-branding 117 and utilizing the social mobilization officers especially in the districts so that we can reach a greater number of our communities and encourage people to call 117 for any and all emergencies!”

— Sally Williams

The 117 Call Center actively participates in the Surveillance Technical working group of the government of Sierra Leone’s One Health Approach Initiative, where the most updated information is shared as received via our call centers to guide interventions. Every day, the 117 Call Center is striving to produce better quality data to drive the evidence-based approach when handling public health issues in the country.