This post is part of the #ProtectingKids story roundup. Read all the stories here.
There is a popular saying that you cannot manage what you cannot measure. This is so true for the global effort to close the immunization gap. We need to localize and measure the gap before we can close it. Having good immunization data to evaluate how well we are reaching all children is a critical ingredient for success.
I was poignantly reminded of this fact a few weeks ago when I visited Damangaza community, an urban slum in Nigeria’s Federal Capital Territory, where one of our Women Advocates for Vaccine Access (WAVA) member works. A temporary settlement, Damangaza is made of mud huts, open sewers, zero infrastructure, friendly adults and playful children. This generous community hosts more residents than it can comfortably accommodate, even welcoming internally displaced families fleeing from Boko Haram. A mere 20 minutes drive from the heart of Abuja, the contrast in wealth and access between the community and the nearby Abuja city center couldn’t be any starker.
When WAVA member, Vaccine Network, began working in Damangaza a few years ago, majority of the children had never been vaccinated. The year before, an outbreak of measles swept through the community killing many children in its wake. Although by no means hard to reach, a community like this is one of many settings where children easily fall through the cracks and are missed by immunization services.
Little wonder current data shows that one in five African children is under-vaccinated. If we are to reach that fifth child, we need accurate and timely data to tell us who that child is, where they live and why they are missed. This is a big challenge in Nigeria where the two main sources of immunization data (survey and administrative) do not speak to each other.
Survey data is obtained by interviewing a representative sample of households in the communities about their child’s immunization status. The main ones are the National Demographic Health Survey (NDHS) or the National Immunization Coverage Survey (NICS) conducted every 4 to 5 years. Survey data is richer in details and considered the gold standard. Administrative data on the other hand is based on clinic and health facility records of children who are vaccinated in fixed or outreach posts; it is collated monthly. It is therefore more available to support program management.
Unfortunately, there is usually wide disagreement between the administrative and survey coverage estimates, with the administrative always higher than the survey for comparable years. For example, national coverage with the third dose of the pentavalent vaccine in the 2013 NDHS survey was 38% but 58% by administrative data. Put another way, survey says we reached nearly 4 in 10 kids while administrative says we reached nearly 6 in 10 kids. Which data is accurate?
Diving deeper in the NDHS 2013 raises concerns about retention in care and equity of coverage. For example, while 51% of Nigerian children get their first dose of pentavalent, only 38% end up receiving all three recommended doses, reflecting an absolute drop out rate of 25%. Furthermore, only a quarter of one-year olds received all required vaccines, while as many as 1 in 5 received no vaccines at all.
Looking the beyond the national average reveals staggering disparities by geography, residence, mother’s education and wealth quintiles. According to the NDHS, a child in the north western state of Sokoto is 32 times less likely to be vaccinated than his peer in the south eastern state of Imo. A child living in a rural area is 2.5 times less likely to be vaccinated than her mate in the city. If a child is born of a mother with no education, that child is 7 times less likely to be vaccinated than another child whose mother has secondary school education or more. Children from the poorest fifth of the wealth ladder are 11 times less likely to be vaccinated than their peers from the richest fifth.
Sobering statistics indeed. As I cradled adorable twins Hassan and Husiana in my arms during my visit to Damangaza, I knew the odds were stacked against them in terms of access to vaccination. Their mother had no education, she was in the lowest rung of the wealth ladder and they live in an urban slum. But then again, it struck me that their disadvantage can be overcome if we are intentional about finding and vaccinating children like them wherever they may be. But we will need good and timely data to do that. If administrative data over estimates coverage, we will have a false sense of accomplishment and still miss many children. If survey data is accurate but comes only twice in a decade, it is too infrequent to help us manage the program. We must find an alternative.
Dr. Chizoba Wonodi is the Nigeria Country Program Lead at IVAC.
As the global community works on ways to improve immunization data, I see a third way. This is to empower communities to generate and use their own data to track births and children’s immunization status. Through IVAC’s work on accountability for routine immunization in Nigeria, I have seen that it is possible use community structures like religious and traditional leaders or Ward and Village Development Committees to count how many children are born in the community every month. If health workers have an accurate number of births in their catchment area, the true target population, it is easy for them to measure how well they are doing with vaccinating kids.
Community structures can also be used to track dropouts or left-outs, tracing them right down to the compound and household where the children live. Such real time information will not only help the health worker do their job better, it will also give community leaders a sense of ownership of the immunization program. I look forward to the day when a village chief can tell his community’s target population and vaccination coverage; that day will bring us many steps closer to bridging the immunization gap. Data is not just for experts and nerds; it is for all of us.
Dr. Chizoba Wonodi is the Nigeria Country Program Lead at IVAC.
This post is part of the #ProtectingKids story roundup. Read all the stories here.
Lakki Marwat, Khyber Pakhtunkhwa, Pakistan
From birth to 15 months, 6 visits to the Immunization Center your child will be protected from 9 vaccine preventable diseases. Repeat after me and memorize these numbers as you did your tables in school.
As some 20 heads nod in agreement, I realized many women and girls sitting in this veranda may never have gone to school. This was an awareness session with community women of Lakki Marwat. The district in Pakistan's northwestern province of Khyber Pakhtunkhwa has a dismally low immunization coverage.
Although it was an all women session, many women had not taken off their burqa (the one which are more popularly known as the shuttlecock burqa which covers them head to toe with just a net near the face to let them see and perhaps breathe a little) for fear that a male glance may fall on them.
Although, I had heard a lot about Lakki Marwat, this was my first visit ever to the place. Khyber Pakhtunkhwa is a conservative province, but Lakki Marwat is by far the most conservative of all the districts.
I was conducting an awareness session with the community women in Lakki. I wanted to speak to young mothers and even mothers in law and tell them the value of vaccination, how it can save their children from diseases and, best of all, it cost them nothing for that. I was also very curious to find out, despite all the benefits, what prevented them from getting their children vaccinated and what could be done to improve the coverage.
I was amazed at the level of excitement and interest. They were all ears, listening in rapt silence. Giving me utmost respect and importance, they raised their hands and patiently awaited their turn if they had a query.
Pakistan is a large country with high child mortality and low immunization coverage. More than 1,000 children under five die each day. Just over half of Pakistani children are fully vaccinated against all nine diseases included in the EPI, with tremendous variation between provinces (Source: 2012-2013 PDHS). It is an important country in the immunization world, and among the last two still fighting the polio virus.
There are severe provincial disparities and marked variations in immunization coverage in provinces and districts, and by gender. A survey conducted to analyze the causes and barriers of routine immunization in three districts of Khyber Pakhtunkhwa (which included Lakki Marwat) by Japan International Cooperation Agency (JICA) late last year indicated an unfortunate 78 percent illiteracy rate amongst women in Lakki district. Knowledge of mothers that children require immunization six times was only 12 percent.
In a comparison on gender differences of children (12-23 months) who had missed routine immunization, that of girls in that area turned out to be 64 percent as compared to boys.
There are several demand and supply side challenges for this low and fragmented progress. Public awareness of benefits is low and local authorities don’t view immunization as a priority. The gap in immunization knowledge among the community impedes them from actively seeking immunization services.
But despite systemic weaknesses, the province is taking impressive steps to not only improve but improve equitable immunization coverage. Lakki Marwat will be amongst the three priority districts in which the provincial government will be working on social mobilization in 2016.
One thing was evident – this was not a place frequented by visitors from other towns, let alone women. I recalled when, during our discussion, the Khyber Pakhtunkhwa EPI Program Manager had, in a sort of challenging cum daring tone, suggested Lakki for the advocacy session with community, if I was really serious in doing a meaningful session. However, while confirming the date and venue, the District EPI Coordinator of Lakki had clearly said I should return home by evening alluding to the place not being safe for women to stay the night.
Knowingly leaving this last piece of information from any conversation I had with my family on my impending visit to Lakki, I did, however, return the same night travelling a good 13 hours on the road. In retrospect, it was one journey I found to be far more satisfying than many others I have taken in my quest to spread the knowledge about the value of vaccinating children against childhood diseases.
Huma Khawar is an IVAC consultant who works on immunization advocacy with stakeholders on the ground in Pakistan.
This article was originally published in Open Magazine and is cross-posted here with permission.
This post is part of the #ProtectingKids blog series. Read the whole series here.
Niya Zameen with her two boys outside their home in Ramsar
Niya Zameen, 33, lives with her two sons in Ramsar, in Barmer district of Rajasthan. Her village has a population of just 1,078 and is close to the India-Pakistan border. Niya has always tried to ensure that her children receive the necessary healthcare services, including vaccines, to give them a healthy start in life. Getting her children vaccinated hasn’t always been easy because of shortages of government recommended vaccines. But Niya has never given up. With the help of the local health worker, Rampatti, she made sure that her children received the necessary vaccines against measles, polio, and three doses of diphtheria-tetanus-pertussis.
Of the 1.3 million Indian children under-5 that died in 2013, pneumonia claimed more than 175,000 lives and diarrhoea caused more than 130,000 deaths. Even in cases of survival, the severe burden of illness from diarrhoea and pneumonia adversely impacts children’s growth and development. But many of these severe illnesses can be easily prevented through immunisation. The pentavalent vaccine, that prevents a deadly form of pneumonia and meningitis, is now available through government immunisation programmes in some states and the vaccine to tackle diarrhoea caused by rotavirus, will soon be rolled out.
Niya Zameen acknowledges the crucial role that Rampatti, the local health worker, plays in her life. She has provided guidance on important health decisions, including the role of vaccines in giving all children protection against preventable diseases.
Vaccine delivery is a challenge in this region, due to extremely hot weather and the difficult desert terrain. If the vaccines don’t arrive on the designated day of immunisation, Rampatti travels to the vaccine cold chain point to collect them for her village. On her return, she vaccinates children.
Every child has the right to a healthy start, and it is the responsibility of not just the government, but also of the community to ensure that all our children are timely and fully immunised.
Photos by Shikha Nayyar
This post originally appeared on the Nigeria Health Watch and is cross-posted here with permission.
By Chizoba Wonodi
Nigeria launched the introduction of the pneumococcal conjugate vaccine (PCV)into its childhood immunization schedule in Lokoja, on December 22nd 2014. PCV prevents one of the deadliest bacterial causes of pneumonia, meningitis, blood infections and middle ear infections in children. Before now, only parents with the means could afford to vaccinate their children for thousands of naira in private clinics. But now, government is offering it for free to all kids. This is a big deal, so get excited!
Launch of PCV Vaccination in Lokoja
A journey that began 6 years ago has finally come to a successful end. But it was not an easy ride. As I think about the road to this introduction, I remember all the twists and turns along the way and marvel at the tenacity and perseverance of the chief actors in this story.
In 2008, I was working for a Johns Hopkins project called PneumoAdip, which was set up to accelerate the introduction of PCV into African and Asian countries. You may wonder why anyone needs a project to do that, right? Well, it turns out that having a vaccine that works is not enough to get countries to use it, unless the vaccine is for Ebola. I bet countries will scramble for an Ebola vaccine, if it comes. But then most diseases are not like Ebola. For more silent diseases like pneumonia, it takes concerted effort to make the decision makers recognize the burden of the disease, the value of the vaccine and the actions to take on it. For example, it took Nigeria 21 years to adopt the Haemophilus Influenza b (Hib) vaccine into our routine system. The first country to use Hib vaccine in their national program started in 1991, we started 2012.
I remember sitting in the Premier Hotel Ibadan during the 39th Annual General and Scientific Conference of the Paediatric Association of Nigeria (PANCONF) in January 2008. The halls were packed, the place was buzzing, the energy was infectious, pediatricians were milling around discussing how to save babies. I had come from Baltimore to field test a pneumonia diagnostic tool and discuss the prospect of Nigeria introducing PCV into the national immunization program.
At one of the session breaks, I cornered Dr. Abanida, then Director of Immunization at NPHCDA and asked him, “Doc, when are we going to introduce penta and PCV?” “Very soon” he replied, “We will apply for both vaccines this year”. This was an unexpected and pleasant surprise. I had predicted he would commit to only penta, but PCV as well? That was great. You see, it was no coincidence that we were coming late to the penta party when countries like Kenya had introduced the vaccine 8 year before. As a country, we had been preoccupied with battling polio, especially after the major polio vaccine rejection of 2004. In addition, our systems were weak. Indeed, before 2005, we would not have been able to apply for Gavi support for new vaccines even our immunization coverage was less than 50%, less than the required threshold. To get Gavi’s help, countries have to meet certain eligibility criteria and they have to formally apply and be approved for support.
Just as Dr. Abanida had declared, in April 2008, Nigeria tendered their first Gavi application for penta and PCV introduction support. In June 2008, the reviewers granted the application a conditional approval.
Disappointed but not deterred, in September 2008, the new vaccine application team led by Dr. Oteri, then Gavi desk officer at NPHCDA, responded to the conditions and queries from Gavi. But the second submission was rejected and the country was asked to re-apply.
Three things then happened that delayed the process for the next two and half years. First, Gavi suspended all new vaccine applications due to internal processes and funding constraints. No country could apply for new vaccine support in 2009. Second, Gavi revised their new vaccine application policy, now requiring an immunization coverage rate of at least 70% instead of 50%. Third, Nigeria’s vaccine coverage dropped below 50% to 42% according to WHO-UNICEF estimate released in June 2010. This new drop caused Dr. Dorothy Esangbedo, then the President of the Pediatric Association of Nigeria, to lament bitterly and call for stronger action to shore up routine immunization.
Under the new policy and with the lower coverage, Nigeria could not re-apply in 2010. In fact, a workshop in August 2010 convened by NPHCDA to develop the third submission was truncated by the twin news that our coverage rate had dropped and Gavi coverage requirement had increased.
When Gavi began revising their policy, there had been talk and expectation in some quarters that countries such as Nigeria, who were already in the application process before the policy change, would be “grandfathered in”. That did not pan out. To help matters, Gavi delayed the implementation of the new coverage requirement by one year, which left Nigeria with one window of opportunity to apply in May 2011.
But there was one more hurdle to scale. Coverage estimates for 2010 had to be 50% or better. The National Immunization Coverage Survey (NICS), showed coverage to be 71% for 2010, but Gavi only recognizes the WHO/UNICEF estimates, which was still 42% and would only be updated in July. Nigeria needed the updated estimates to apply in May. The update would be two months late. What to do?
The emails and phone calls started going back and forth advocating for a solution. At IVAC we pushed for different options: allow Nigeria use the NICS to apply, allow a phased introduction, so that states that meet the coverage criteria can be supported to introduce the vaccine, while effort be made to raise coverage in the other states. Dr. Mohammad Ali Pate, then Minister of State for Health, was very vocal in his advocacy to find a solution. Eventually and exceptionally, Gavi allowed Nigeria to apply for penta and PCV in May 2011. Then in July 2011, penta was approved and PCV was conditionally approved. All decisions were subject to the 2010 WHO/UNICEF DTP3 coverage estimates being >50%.
After the July 2011 conditional approval for PCV, Nigeria worked on responding to the conditions attached to the approval by strengthening the cold chain system. Then, 15 months later, in October 2012, Gavi gave the final approval for a phased roll out of PCV to begin in 2013. However, due to global supply constraints and other operational issues such as strikes in the Nigerian health sector, the first child could not be vaccinated till December 2014.
I didn’t go for the launch, but my colleagues went, and it was gratifying to see the culmination of everyone’s effort. Big thanks should go to the NPHCDA, Gavi, UNICEF, WHO, Pediatric Association of Nigeria, CHAI and all other groups who have pushed hard to see this happen.
First Nigerian Child to receive the Free Pneumococcal Conjugate Vaccine
As I look at the grainy picture of baby Collins, who is the first child to be vaccinated, cry out in pain from the shots of the first PCV vaccination, I wish I could tell him,
“Baby, don’t cry, laugh instead, even though that injection is painful. You are getting a shot a life. Something that babies before you did not get, but thankfully those after you will receive. If we are able to immunize 87% of your fellow babies every year with this vaccine, we can save about 200,000 lives by 2020. Isn’t that something to laugh or even rejoice about? Yes indeed, it is cause for celebration. I only wish it didn’t take six long years for this to happen. Think of all the babies we could have saved in that time. Anyway, you are too young to understand all this. After all, what do you know? You are just a baby. You probably just want to suck you mother’s breast right now, forget all this noise and go to sleep. So I’ll let you be.”
Dr. Chizoba Wonodi (MBBS, MPH, DrPH),
Nigeria Country Programs Lead, Johns Hopkins International Vaccine Access Centre,
Advisor, Saving One Million Lives Initiative,
Advisor, Gavi’s Strategic Demand Forecast for vaccines.
This post originally appeared on the VaccinesWork blog and is cross-posted here with permission.
By Huma Khawar
In 2012, Pakistan was the first South Asian country to introduce the pneumococcal vaccine with Gavi support. Provided free of charge to children under the age of five, the vaccine protects against a major cause of pneumonia, a disease that is a major killer of children worldwide. But in order for any vaccine programme to be successful, information and support are essential. And where do many people get their information? The media.
The question and answer session in action. Photo: Huma Khawar
Dr Taimoor Shah, Deputy Director Khyber Pakhtunkhaw province’s Expanded Programme on Immunization (EPI), knows this well. On World Pneumonia Day last November, he took the opportunity to gather a room full of journalists of all backgrounds at the Press Club in Peshawar, to talk specifically about the pneumococcal vaccine and to answer their questions.
The result was a discussion that sounded more like a medical classroom than a group of reporters. How many vaccines are included in a child’s immunisation programme? What are the diseases that can be prevented through immunisation? How expensive is the pneumonia injection? It was difficult to decide whether to feel surprise at the lack of awareness among the media about vaccine preventable diseases or to be happy at the eagerness and genuine interest expressed in the reasons for Pakistan’s high rates of child mortality.
The session was both informal and interactive. Journalists from different organisations suggested ways to educate people on vaccination and eradication of fatal diseases through media messages. They concluded that it was the common duty of parents, government health institutions, media and civil society to take steps for overcoming health issues through vaccination and timely treatment.
One journalist confessed that although he knew all about how and when to give the different vaccinations, he didn’t know the importance of each. ”It will be easier, he said, to convince mothers on the importance of getting their babies immunised.”
The session also gave the health journalists an opportunity to express their own opinions and share insights. They talked openly about how, over the years, with so much money and emphasis directed towards polio eradication, routine immunisation had taken a backseat.
By the end of the session, some 30 plus media personnel had learned much more about vaccines and routine immunisation. One digital reporter admitted that this type of question and answer sessions was essential as a vast majority of journalists have limited knowledge of vaccines and their potential.
“A lot of mothers get their information from newspapers. Media should be up to date. If their knowledge is suspect, they will pass on wrong information to parents. This can be very dangerous,” he said.
And in a country where each year one in twelve children born die before reaching the age of five, many of them due to vaccine-preventable diseases, spreading this newfound knowledge can only be a good thing.
Photo: Humar Khawar
Huma Khawar is a freelance journalist and IVAC communications consultant who works in Pakistan.