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Experience of integrating vitamin A supplementation into polio campaigns in the African Region

Wednesday, 5th of October 2016

 

Vaccine, Volume 34, Issue 43, 10 October 2016, Pages 5199–5202

Polio Eradication Initiative Best Practices in the WHO African Region

Experience of integrating vitamin A supplementation into polio campaigns in the African Region

• Elizabeth Tangel Chehab^{a, ,} ,
• Blanche-Philomene Melanga Anya^b,
• Adelheid Werimo Onyango^b,
• Mable Carole Tevi-Benissan^b,
• Joseph Okeibunor^b,
• Pascal Mkanda^b,
• Richard Mihigo^b

 

Highlights

•Vitamin A deficiency in children constitutes a challenge to public health the African Region.

•PEI provided a platform for integrated delivery of vitamin A in the African Region.

•The lessons and experiences were captured in this paper.

Excerpts below; full text is at http://www.sciencedirect.com/science/article/pii/S0264410X16303826

Abstract

Introduction

Vitamin A deficiency is a public health problem that affects children across the WHO African Region. Countries have integrated vitamin A supplementation in different child health interventions, most notably with polio campaigns. The integration of vitamin A in polio campaigns was documented as a best practice in Angola, Chad, Cote d´Ivoire, Tanzania, and Togo. There are potential risks to vitamin A supplementation associated with the polio endgame and certification in the African Region.

Methods

We reviewed the findings from the documentation of best practices assessment that was conducted by the WHO Regional Office for Africa in 2014 and 2015 in the five countries that noted integration of vitamin A with polio as a best practice. In addition, we reviewed the coverage rates for oral poliovirus vaccine and vitamin A supplementation in Angola, Chad, Cote d´Ivoire, Tanzania, and Togo in 2014 and 2015.

Results

Vitamin A deficiency in 2004 ranged from 35% in Togo to as high as 55% in Angola. All five countries integrated vitamin A supplementation in at least one campaign in 2013–2014 and all achieved over 80% coverage for vitamin A supplementation when it was integrated with polio.

Discussion

Given the progress of the polio program, and decreasing campaigns, there is a risk that fewer children will be reached each year with vitamin A supplementation. We recommend that for countries strengthen the integration of vitamin A supplementation with routine immunization services.

Abbreviations

• GPEI, Global Polio Eradication Initiative;
• OPV, oral polio virus;
• SIAs, supplementary immunization activities;
• UNICEF, United Nations Children´s Fund;
• WHO, World Health Organization

1. Introduction

Vitamin A deficiency is a major public health problem that affects preschool age children primarily in the regions of Africa and South East Asia [1]. Inadequate or low intakes of vitamin A between the ages of 6 and 59 months can lead to vitamin A deficiency which in severe cases can cause visual impairment, night blindness as well as an increased risk of illness from infections such as measles and diarrhoea [2]. World Health Organization (WHO) regional estimates indicate that the highest proportion of preschool age children affected by night blindness is in Africa at 2% which is four times higher than estimated rates in South East Asia at 0.5% [2]. Vitamin A deficiency is among the 19 top risk factors for childhood death globally and is responsible for close to 6% of child deaths in Africa [3]. WHO guidelines recommend vitamin A supplementation in infants and children ages 6–59 months once every 4–6 months in settings where vitamin A deficiency is a public health problem [4].

Countries in the WHO African Region have integrated the delivery of vitamin A supplements to children in routine immunization services. The national schedules adopted usually are based on schemes suggested in the WHO Guideline for Vitamin A Supplementation in infants and children 6–59 months of age [4]. It is recommended that immunization be part of a comprehensive strategy that includes promotion of breastfeeding, vitamin A supplementation, safe drinking water, and sanitation [5]. In addition to routine immunization, countries have used other health program platforms such as child health days and the integration with polio supplemental immunization activities (SIAs) to give doses of vitamin A.

Using polio as a platform to provide vitamin A supplementation globally was documented in a paper published in 2000 [6]. The Global Polio Eradication Initiative (GPEI) is closer than ever to eradicating polio noting that at the time of this writing, the most recent case of wild polio virus was reported from Nigeria in July 2014 [7]. However, until polio-free certification of the region is completed, countries in the African Region, still at risk of polio importation or with low immunity profiles, continue to run SIAs with close to 100 rounds conducted in 2015 [8].

In 2014 and 2015 the WHO Regional Office for African conducted an eight-country assessment of best practices in integration of vitamin A with polio campaigns. Among the eight, five countries (i.e., Angola, Chad, Cote d´Ivoire, Tanzania, and Togo) qualified as best practice examples.

The purpose of this paper is to review and describe what constituted best practice in the use of polio as a vehicle for vitamin A supplementation in the five countries, and to consider potential risks to vitamin A supplementation associated with the polio endgame and certification in the African Region.

2. Methods

We reviewed the findings from the documentation of best practices assessment that was conducted by the WHO Regional Office for Africa in 2014 and 2015 which noted integration of vitamin A supplementation in polio campaigns as a best practice in five of the eight countries assessed (i.e., Angola, Chad, Cote d´Ivoire, Tanzania, and Togo). Our analysis included an in-depth review of the methods for planning, organizing, and implementing polio SIAs including the administration of vitamin A supplementation in the five countries. In addition to a review of the best practices reports, a comprehensive review of the coverage rates for oral polio virus (OPV) and vitamin A supplementation was conducted for all five countries.

The best practices were grouped into the following three categories: campaign planning, implementation of campaign, and post campaign activities.

2.1. Campaign planning

In all five countries, cross program coordination teams were put in place and planning coordination meetings were held between Expanded Program on Immunization (EPI) and nutrition stakeholders to ensure a common understanding of vitamin A supplementation and delivery of OPV for the planned campaigns. A detailed budget was developed to provide for both interventions and included human resources, training, supplies, transportation, and any other associated costs of delivering the interventions. The coordination teams conducted resource mobilization through government, WHO, the United Nation Children´s Fund (UNICEF) and other partners as needed in addition to ensuring the timely availability of funds to implement the campaign.

Microplanning activities were conducted and a detailed action plan was developed to ensure that target populations were clearly defined and that the campaign reached as many children as possible including nomadic and other hard to reach children. Government, religious, and local leaders were visited and advocacy was conducted on the importance of polio vaccination and vitamin A supplementation. Other social mobilization activities were also conducted including television spots, radio segments, printing of banners, and T-shirts to ensure communities were aware of the campaign. Focus was placed on the addition of vitamin A supplementation to polio immunization to encourage more parents to bring their children.

Training of supervisors and vaccinators was completed for regular OPV distribution as well as training and correct vitamin A dosing, how to dispose of used capsules, and how to record and calculate coverage. This training was critical for overcoming the difficulties of administering multiple interventions in one campaign as was noted by field staff in Angola and Cote d´Ivoire during the best practices documentation exercise. For data collection, tally sheets, tools, and checklists were revised to include vitamin A in addition to OPV to ensure ease of using one form.

2.2. Implementation of the campaign

The campaigns began with an official launching ceremony where the importance of polio vaccination and vitamin A supplementation was explained to the population. Continued social mobilization activities and awareness raising were done throughout the campaign which typically lasted 2–4 days. The campaigns were conducted according to detailed action plans with vitamin A given after OPV as per WHO guidelines [8].

In Chad, averages of 3–4 campaigns are conducted per year targeting the whole country and typically included the integration of vitamin A supplementation twice per year. An estimated 3.5% of the Chadian population is nomadic [9], with children that can be difficult to reach for immunization. Chad therefore worked to specifically target polio campaigns and thereby vitamin A supplementation in nomadic children by tracking nomadic movements. The authorities agreed on flexible dates of campaigns with local leaders and chiefs, and worked in collaboration with them to ensure adequate awareness-raising in those communities [9].

With regard to data collection and reporting in all five countries, vaccinators and supervisors ensured that data for both interventions were recorded and underwent daily synthesis. Refusals and adverse events were documented and managed and health care workers were supervised and their work monitored. In Togo, it was specifically noted that activities included daily meetings during the campaign for monitoring and oversight [10].

2.3. Post-campaign activities

At the completion of the campaign, all coverage data on OPV and vitamin A doses were collected and reported to the next higher level (i.e., district to regional and regional to national) and independent monitoring activities were conducted to verify the coverage data collected. Post campaign review meetings were held by the coordination teams to consolidate lessons learned and finalize campaign reports.