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On Wednesday, 13 June 2012, the Ugandan Ministry of Health did a self-examination of the just completed integrated measles/polio campaign, covering all 112 districts of the country.
In this meeting, several hardy perennials sprouted. Messaging was right: all stakeholders referred to the campaign as for under-fives, not, ambiguously, as for ‘up to fives.’ Funds flow was late in parts of the country, and some vaccinators withheld their tally sheets while waiting for payment. The campaign would have gone better if all items had been pre-positioned well in advance. One 2 year old girl choked on her albendazole tablet. Could staff be trained to treat such rare cases?
Two decisions face Uganda in 2012, the year of its next triennial measles campaign:
1) Will it give measles or measles/rubella vaccine? If the latter, then with likely GAVI funding
2) If Africa goes for global eradication, will house to house social mobilization be needed to achieve 95 percent coverage in all districts? How much is the price tag on this highly effective strategy?
The acting UNEPI Director opened the meeting, which brought together >40 participants from the government and partners. This is a joint meeting between the NCC and the central MoH team, as well as Red Cross, USAID, WHO and UNICEF.
After the opening prayer and introductions, the D-G welcomed all participants. She hoped that the field teams were bringing back good news from the field. She thanked the organizers of the launch, which covered EPI, ivermectin mass drug administration (MDA), and Child Days Plus. She thanked the UNEPI team and partners for their good work, especially the social mobilization team. This campaign was on the radio every minute. National Medical Stores was of great help, with pre-positioning of vaccines and supplies one week before the campaign start.
Challenges: The National Co-ordination Committee held a number of meetings; the NCC had to postpone the campaign once. However, funding issues still came up, and we have not met our obligations in all districts. We thank all the districts, funded and unfunded, for their hard work. We lost a two-year-old girl during the campaign. This was from asphyxia from albendazole in her airway. We need to emphasize that the children start with the oral preparations first, then the injections.
We shall go straight to our program.
Jacinta, the acting UNEPI programme manager gave a presentation on the campaign results, based on submissions from districts and campaign supervisors.
The 2011 RI coverage was 75 percent for measles. We got into outbreaks before the SIA.
The NCC (national coordinating committee) operated with wide membership, using five subcommittees.
Supervision was done from central and district levels, including participation of district leadership.
The dates were 26 through 28 May, with press release by Hon Minister of Health, with launch by President Museveni in Pader District, with 112 districts implementing and two days of mop-up; Kampala mop-up is still pending.
One district, home to the Namayuingo Islands, was phased.
Results from the districts which have thus far reported:
Measles OPV
|
|
Measles |
OPV |
|
>100 percent |
48 districts |
52 districts |
|
95-100 percent |
12 |
7 |
|
85-95 percent |
6 |
6 |
|
50 to 85 percent |
10 |
11 |
|
Reporting districts |
76/112 |
76/112 |
Support: WHO, UNICEF, RC, DFID, USAID, LDS, Rotary, Lions Club, NMS
The Sironko District presentation discussed special efforts for those areas where vaccines are regarded as demonic. The local councillors, LC1s, did house to house mobilization district wide. Health workers were mapped by subcounty. This district reported no severe AEFI. The LC1s participated in the mop-up, which started on Saturday, 9 June. Mop-up was limited to subcounties without vaccinated children. Best practices: efforts by all stakeholders to mobilize the population. Challenges: late receipt of funds for mop-up; inadequate tally sheets.
Overall coverage was 101 percent, but with variations by subcounty. There were 8/21 subcounties reporting <100 percent for measles, largely where there were religious objections.
Isingiro District, recently created, reported difficulties with funds flow. Both polio and measles coverage exceeded 100 percent. In some areas, social mobilization from the government side was not active. Social mobilization went well where UNICEF funding was present. Cold chain and freezing capacity were well done; there were spot shortages of measles vaccines at some sites. All materials were available; where stockouts occurred, this was because of poor distribution. Injection safety was well done. Waste management was not adequate. We had no serious AEFI. We had adequate albendazole and vitamin A. Funding was not available for mop-up. Best practices: early freezing of icepacks, which were refrozen at day’s end for the following day.
The way forward: register all children so that we can identify those missed.
Coffee Break
During the coffee break, the UNICEF SIA consultant said that he would like to have seen coverage estimates for below the district level. The parish data might be telling a different story from the grouped district figures.
WHO report, Andrew Bakainaga
Independent monitoring (IM) data are not yet available; our monitors complete their work this Friday. We worked on monitoring and supervision, covering Kampala and four other districts. We noted that in all regions with WHO participation, all districts had completed the microplanning process. The microplans formed the basis of the budgets. The CAOs were critical in financing the campaign, especially where funds flow was late, as in the South. This led to prompt start on the 26th. The leadership and commitment of district health officers was remarkable in most districts. There was a great involvement of the political leadership, especially the local councillors, LC5s. Implementation funds arrived late in many areas. The microplans were not translated into operational plans, e.g., detailed distribution plans. We also realized that in some districts, there were hard to reach areas (whether from geography or difficult to convince populations); plans to reach these were not well defined or implemented.
Some launches, including the presidential launch, for the nodding disease campaign brought the SIA to the fore. The local councilors assisted with refusals. Radio talk shows were heard in most districts. There were, in general, enough frozen icepacks, vaccine carriers.
There was high demand everywhere, especially on Days 2 and 3. In some districts, local councilors did preregistration and defaulter follow-up, which contributed to high coverage. On Sunday, sites were assigned to places of worship.
Weaknesses: Training was not done for lack of funds; IM admin of measles, erroneous finger marking, weaknesses in deployment of mobile teams for remote areas. Most districts had not received IEC materials, such as flyers. Some districts were short of transport for supervision. In some districts, there were shortages of diluent on Day 2. Some districts did not get cards and tally sheets, which presented challenges. There was a shortage of vitamin A and albendazole, as well as Child Day tally sheets.
The way forward: The future campaigns should have dates set after confirmation of funds availability, as distinct from pledges. Social mapping of rejectionists, especially in Mbale, is necessary. The IEC materials were often wasted because of late distribution. Prepositioning, 2 weeks in advance, is needed. If this problem persists, use your social mobilization funding in other areas.
Districts should be encouraged to develop operational plans, based on the microplans. There is a need for early involvement of faith based organizations (FBOs) and traditional leaders, to avoid religious objections to vaccination.
Maldistribution of supplies from the district to the field points to the need for developing distribution plans to avoid overstocking and stockouts.
Eva Kabwongera introduced their polio consultant and Bonifacio Raul, the measles SIA consultant, who presented. UNICEF supported 7 geographical areas.
Planning and coordination
Strengths:
Challenges
Top down microplans not translated at parish level
Social mobilization
Strengths:
Challenges:
Cold Chain
Strengths:
Challenges:
Monitoring and supervision
Strengths:
Tally sheets used systematically
Challenges:
Implementation
Strengths:
Challenges:
Best practices:
Recommendations:
John Barenzi presented on behalf of the Uganda Red Cross Society.
URCS was involved with support from Amcross. We worked in 14 districts, including Kampala and Wakiso. In the upcountry districts, things went well. In Kampala, there were problems. We have a coordinator and a mobilizer in each of the capital’s five divisions. We were able to assemble a team of young people. We tried to align our services with those of LC1s, moving house to house to inform the public. The participation of LCs in Kampala was lukewarm. They expected payments, which were not forthcoming. URCS supported KCC and upcountry with transport, loaning one vehicle to each upcountry district. In Kampala, we still had only two vehicles for the capital, which was inadequate. H2H mobilization was done before the campaign so they would come in starting on Day 1. The H2H mob was not total, since 579 volunteers were not enough to cover the entire population. We did a quick survey to look at the percentage of mothers were informed by the mothers. URCS trailed radio, which was first, as a maternal information source.
Challenges: Many vaccination centres opened late or not at all. There was miscommunication. Some volunteers expected transport to centres. Covering the largest, high volume centers with a single volunteer was not adequate. HWs were not content because of non-payment. Many were unwilling to hand in their tally sheets. The quality of vaccination services was poor. The diluent was sometimes set on the table. Injections were intramuscular in many cases. This shows that training was hurriedly done. URCS will participate in the Kampala mop-up this weekend.
There was no LDS presentation.
The Lions Club did not present.
The mass drug administration team (MDA) did not present.
The Office of the Prime Minister spoke next. The RDCs, resident district commissioners, have a constitutional mandate to monitor all activities in their districts. They reported successful implementation, despite challenges, such as shortages of drugs (albendazole and vitamin A), and, in Nguru District, use of minors as caregivers. In one district, bad roads hampered movement of health workers. In one district, born again churches objected to the vaccinations. As UNICEF said, there has to be enough advance preparation to make sure that things go well.
Child Days Plus presented next.
The polio and measles campaign were to merge with Child Days Plus. However, some districts started CDP before the 26th. Moreover, some districts did not have CDP tally sheets. Because timing was not uniform, monitoring was sometimes difficult. All the same, we appreciated the operation. CDP should have waited in some districts. Logistics were present in some district, absent in others. Our most serious problem was stockouts of albendazole. The distribution mechanisms were poorly developed.
Discussion
Patrick Isingoma spoke as a district supervisor. The Stanbic Bank supported the launch in one subcounty. We found it hard to reach the market women and used the Lions to bring them in.
We had a needlestick injury in one site. The HW mishandled the situation.
Another discussant: how can you have many children unvaccinated in districts with coverage over 100 percent?
Bob Davis said:
1) In Uganda as elsewhere, funds flow and prepositioning of supplies were major challenges.
2) The messaging in Uganda was consistent: under-fives. This is a lesson for other countries.
3) TV, radio and house visits were all important. Printed items (flyers, brochures, banners, posters) were mentioned by <2 percent of all caregivers in Kampala.
4) Mass media do not reach non-owners of radios and TVs. More systematic house visiting is needed.
5) LC1s have to get on board, in future, for preregistration and defaulter follow-up.
6) Red Cross deployed 1000 volunteers in Dar es Salaam, which was enough. In Kampala, 579 volunteers were insufficient to cover all households.
One participant: Some religious communities, as noted in previous campaigns, resist vaccination, especially but not exclusively in western Uganda. The Director of Clinical Services should take up this problem.
Another participant, central store supervisor: Our problem was funds. HWs hid their tally sheets awaiting payment.
We had three suspected AFP cases. Samples were taken.
We had one AEFI case in one center. The child recovered after sweating on the lip.
Wherever I went, the health workers were poorly trained. They did not know how to record zero doses.
Another participant: In Moyo, on the South Sudan border, they got coverage >100 percent. However, we had people from outside getting shots in these places, which explains the overestimates. It doesn’t matter where a child is vaccinated, if s/he is vaccinated.
We had some Sudanese coming to Moyo early in the morning.
The local councillors asked for money, to which they are no longer entitled.
Participant from Karamoja: I saw few IEC materials in Kotido. The deliveries of IEC materials were not made. These are still in the store.
Another participant: Urban areas were sometimes hard to reach because of resistant Somalis and Karamojong. We used the mosques to correct false impressions.
Where coverage exceeds 100 percent in border areas, this is, for example, because of Kenyans coming into Busia. In Busia, LC1s got money from CAOs as an incentive.
In one district, we used LCs successfully to speak with refusers. LCs motivated mothers to get shots by telling mothers that the EPI card was a prerequisite to accessing government health facilities.
John Barenzi: We are considering increasing the number of volunteers deployed to the slums. Now that we have supported the upcountry transport, we will deploy one vehicle for each of the five divisions in Kampala.
Another participant: In a Millennium Village district, the services were quite efficient. The HW is quite good, and coverage was high.
In another district, there were many zero doses. This does not mean that the campaign was a failure, but that it made up for the failures of RI.
Eva Kabwongera: There was a big problem with IEC materials distribution for Karamoja. Logistics were a problem in the campaign.
PM’s Office rep: When the RI falls short of a certain level, the answer is to respond with mass immunization. We must go beyond this discussion. Why have we seen declines in health facility deliveries? How do we return to better use of routine health services? This is a cross cutting issue, not just touching EPI. You use the RDC and the LC5 to revive routine services.
How do we overcome religious objectors?
With more access to cash, there is a decline in voluntarism.
On cross border districts, you will see people coming. This is good, because it prevents cross border measles transmission.
A district supervisor: In Adere, we had poor coverage on Day 1. We used all means at our disposal, including teachers and pupils, to look for unmarked children. Any village without marked children was targeted for mobile teams.
Mass drug administration, done at household level, limited frequentation of fixed posts, which gave OPV and measles.
We counted vials against tally sheets to find inconsistencies in tally sheets.
There were no scissors to open the vitamin A capsules. People used fingers to pinch the capsules.
In the subcounty with the presidential launch on Day 1, coverage shot up on Day 2.
Mop-ups were highly successful, with coverage at 96 percent by Day 2 of the mop-ups.
We saw subcounty figures which were not consistent with the data from the districts of which they formed a part.
Another participant:
Challenges in Kampala: much of Wakiso is similar to Kampala. Should these areas be treated like Kampala for mop-up?
Diluent: some centers hold diluents to use as water for injection. This is incorrect. Let’s explore this.
Targets: we are not using correct denominators. This is why coverage exceeds 100 percent in some places. Let’s review the 21.4 and 19.2 percent, respectively, as OPV and measles proportions.
Another participant, from Mitoma:
Let’s do more convenience monitoring.
There was one arrest of a police officer who tried to charge EPI Sh 10,000 for car parking in the police compound.
Another participant, from Kumi district:
There are some objections to finishing Child Days, then starting measles SIAs the next week. Why this heavy overlap in services between CDs and SIAs? Once these are completed, should routine outreach continue?
UNEPI manager, responding: We use 20.5 percent for OPV and 18.5 percent of total population for calculating target populations for measles. We use the same denominators for all 112 districts.
We revaccinate because MCV1 at 9 months produces only 85 percent efficacy.
Refugee camp vaccination is difficult when children are trucked from site to site. We have used district authorities to halt the premature dispatch of unvaccinated kids.
Mbarara supervisor: Training was lacking. They were injecting IM instead of subcutaneously. Nursing assistants were doing better than nurses! (groans from the audience) We need to look at how to improve training for future campaigns.
Shema district supervisor: the LC5 and LC3 did not participate because of problems with the CAO. These guys were recommending the CAO for transfer. The HWs have not yet been paid. The HWs are bitter because of nonpayment.
Amuru and Moya district supervisor: Coverage was about 100 percent, but I’m not sure of this figure. We had many challenges in both districts [detailed account]
Afternoon Sessions
One participant: Kampala vaccinators were not paid, and hence refused. KCC voted to use students, and those students were not paid.
One district supervisor: Prepayment of vaccinators creates headaches. It is hard to get data from them when you have no stick with which to beat them.
Another district supervisor: we had much success with the H2H social mobilization. In lakeside areas, we needed more motorcycles.
In Kasesa, we needed 4WD vehicles to reach hard to reach areas.
Another district supervisor: we saw a school outbreak of 11 suspected measles cases in children aged 5 to 11. We followed WHO advice in taking blood samples.
Acting UNEPI Director, Best practices
1 High level political advocacy
2 Multi sectoral planning at national and district level
3 HPAC and HDP, especially in the area of res mobilization
4 Media support before, during and after implementation
5 Community valuing health, high demand
6 Cascading supportive supervision
7 Committed HWs and mobilizers
8 Build capacity for the districts to conduct training for their own HWs and mobilizers
9 Integrated child survival interventions increased demand for the campaign.
Challenges:
1 Resistant religious sects
2 Challenges in distribution of IEC materials
3 Influx of kids from neighboring countries
4 Influx of refugees from DRC
5 Delayed funding, resulting in
6 Delayed departure of central teams due to delayed release of funds
7 Distribution of logistics at district level and below, mostly due to transport challenges
8 Inadequate transport at central level contributed to delays in delivering monitoring tools
9 Inadequate coordination of MoH programs
10 Challenge of denominator (UBOS projected much lower than the actual pop)
11 Challenges of human resources
12 Death of 2 year old from asphyxia after taking albendazole
Way forward:
1) Use LCs to register all children in their jurisdiction
2) Develop health communications strategy for UNEPI and Child Health
3) GoU should make by-laws on vaccination
4) Do mapping of unvaccinated and resistant populations.
5) Work with MoE and Ministry of Sports – school entry requirement
6) Mothers to bring in EPI cards for medical services
7) Emphasize integration.
8) Do ongoing training of HWs.
9) Give feedback to the different key stakeholders.
10) Engage CAOs for RI and campaigns.
11) Specific interventions to reach hard to reach populations.
12) Liaise with UBOS to revise targets.
13) Fix dates once we are sure we have resources (pool resources, basket funding)
14) Review the fixed posts based on the district circumstances.
15) Harmonize messages.
16) Identify low performing districts for early implementation of the RED approach.
17) Involve regional member states collectively to implement.
18) Revitalize outreach circuits for RI.
19) Supervision should start with training.
20) Reactivate the committees responsible for supervision.
21) Increase T-shirts.
22) Revise HWs’ allowances and transport.
23) Increase the number of HWs.
24) Use PA system in urban areas.
25) Increase SIAs from 3 days to 4.
26) Train CHWS to give at least OPV.
27) Train HWs in emergency care for, e.g., asphyxiation.
28) Budget fuel, etc. for hard to reach areas, especially islands.
29) Newly created posts should be maintained.
30) Hold quarterly review meetings of central supervisors.
31) Assure early release of funds.
32) Train HW for hard to reach areas.
33) Create cold chains in newly created districts.
34) Follow up on payments of health workers who implement SIAs
35) Carry out bottom-up planning, especially at the parish level.
36) Continuous funding to the health worker
37) MoH to advocate for transport, helicopters to reach hard to reach areas
38) Strengthen surveillance.
Caregivers’ Source of Information
I communicated the following information, from interviews with caregivers at vaccination sites.
1) TV and radio, in both English and Luganda, came in first as information sources. DHS data (see Table 2) show that mass media are necessary but not sufficient.
2) House visits (by Red Cross and other partners, such as the LDS Church) reached some persons not accessible by the mass media.
3) The little used megaphones did well; more expenditure on these might have generated a greater yield.
4) Print media and printed items, including newspapers, posters, flyers, and banners, played an insignificant role.